Elizabeth S. Chumanov

Hamstring Strain Injuries: Recommendations for Diagnosis, Rehabilitation and Injury Prevention

UNLABELLED Hamstring strain injuries remain a challenge for both athletes and clinicians, given their high incidence rate, slow healing, and persistent symptoms. Moreover, nearly one third of these injuries recur within the first year following a return to sport, with subsequent injuries often being more severe than the original. This high reinjury rate suggests that commonly utilized rehabilitation programs may be inadequate at resolving possible muscular weakness, reduced tissue extensibility, and/or altered movement patterns associated with the injury. Further, the traditional criteria used to determine the readiness of the athlete to return to sport may be insensitive to these persistent deficits, resulting in a premature return. There is mounting evidence that the risk of reinjury can be minimized by utilizing rehabilitation strategies that incorporate neuromuscular control exercises and eccentric strength training, combined with objective measures to assess musculotendon recovery and readiness to return to sport. In this paper, we first describe the diagnostic examination of an acute hamstring strain injury, including discussion of the value of determining injury location in estimating the duration of the convalescent period. Based on the current available evidence, we then propose a clinical guide for the rehabilitation of acute hamstring injuries, including specific criteria for treatment progression and return to sport. Finally, we describe directions for future research, including injury-specific rehabilitation programs, objective measures to assess reinjury risk, and strategies to prevent injury occurrence. LEVEL OF EVIDENCE Diagnosis/therapy/prevention, level 5.

Effects of step rate manipulation on joint mechanics during running.

PURPOSE the objective of this study was to characterize the biomechanical effects of step rate modification during running on the hip, knee, and ankle joints so as to evaluate a potential strategy to reduce lower extremity loading and risk for injury. METHODS three-dimensional kinematics and kinetics were recorded from 45 healthy recreational runners during treadmill running at constant speed under various step rate conditions (preferred, ± 5%, and ± 10%). We tested our primary hypothesis that a reduction in energy absorption by the lower extremity joints during the loading response would occur, primarily at the knee, when step rate was increased. RESULTS less mechanical energy was absorbed at the knee (P < 0.01) during the +5% and +10% step rate conditions, whereas the hip (P < 0.01) absorbed less energy during the +10% condition only. All joints displayed substantially (P < 0.01) more energy absorption when preferred step rate was reduced by 10%. Step length (P < 0.01), center of mass vertical excursion (P < 0.01), braking impulse (P < 0.01), and peak knee flexion angle (P < 0.01) were observed to decrease with increasing step rate. When step rate was increased 10% above preferred, peak hip adduction angle (P < 0.01) and peak hip adduction (P < 0.01) and internal rotation (P < 0.01) moments were found to decrease. CONCLUSION we conclude that subtle increases in step rate can substantially reduce the loading to the hip and knee joints during running and may prove beneficial in the prevention and treatment of common running-related injuries.

Hamstring muscle kinematics during treadmill sprinting.

INTRODUCTION/PURPOSE The objective of this study was to characterize hamstring muscle kinematics during sprinting, so as to provide scientific data to better understand injury mechanisms and differences in injury rates between muscles. METHODS We conducted three-dimensional motion analyses of 14 athletes performing treadmill sprinting at speeds ranging from 80 to 100% of maximum. Scaled musculoskeletal models were used to estimate hamstring muscle-tendon lengths throughout the sprinting gait cycle for each speed. We tested the hypothesis that the biceps femoris (BF) long head would be stretched a greater amount, relative to its length in an upright posture, than the semitendinosus (ST) and semimembranosus (SM). We also tested the hypothesis that increasing from submaximal to maximal sprinting speed would both increase the magnitude and delay the occurrence of peak muscle-tendon length in the gait cycle. RESULTS Maximum hamstring lengths occurred during the late swing phase of sprinting and were an average of 7.4% (SM), 8.1% (ST), and 9.5% (BF) greater than the respective muscle-tendon lengths in an upright configuration. Peak lengths were significantly larger in the BF than the ST and SM (P < 0.01), occurred significantly later in the gait cycle at the maximal speed (P < 0.01), but did not increase significantly with speed. Differences in the hip extension and knee flexion moment arms between the biarticular hamstrings account for the intermuscle variations in the peak lengths that were estimated. CONCLUSIONS We conclude that intermuscle differences in hamstring moment arms about the hip and knee may be a factor contributing to the greater propensity for hamstring strain injuries to occur in the BF muscle.

Gender differences in walking and running on level and inclined surfaces

BACKGROUND Gender differences in kinematics during running have been speculated to be a contributing factor to the lower extremity injury rate disparity between men and women. Specifically, increased non-sagittal motion of the pelvis and hip has been implicated; however it is not known if this difference exists under a variety of locomotion conditions. The purpose of this study was to characterize gender differences in gait kinematics and muscle activities as a function of speed and surface incline and to determine if lower extremity anthropometrics contribute to these differences. METHODS Whole body kinematics of 34 healthy volunteers were recorded along with electromyography of muscles on the right lower limb while each subject walked at 1.2, 1.5, and 1.8m/s and ran at 1.8, 2.7, and 3.6m/s with surface inclinations of 0%, 10%, and 15% grade. Joint angles and muscle activities were compared between genders across each speed-incline condition. Pelvis and lower extremity segment lengths were also measured and compared. FINDINGS Females displayed greater peak hip internal rotation and adduction, as well as gluteus maximus activity for all conditions. Significant interactions (speed-gender, incline-gender) were present for the gluteus medius and vastus lateralis. Hip adduction during walking was moderately correlated to the ratio of bi-trochanteric width to leg length. INTERPRETATION Our findings indicate females display greater non-sagittal motion. Future studies are needed to better define the relationship of these differences to injury risk.

Hamstring Musculotendon Dynamics during Stance and Swing Phases of High Speed Running

INTRODUCTION Hamstring strain injuries are common in sports that involve high-speed running. It remains uncertain whether the hamstrings are susceptible to injury during late swing phase, when the hamstrings are active and lengthening, or during stance, when contact loads are present. In this study, we used forward dynamic simulations to compare hamstring musculotendon stretch, loading, and work done during stance and swing phases of high-speed running. METHODS Whole-body kinematics, EMG activities, and ground reactions were collected as 12 subjects ran on an instrumented treadmill at speeds ranging from 80% to 100% of maximum (avg max speed = 7.8 m·s(-1)). Subject-specific simulations were then created using a whole-body musculoskeletal model that included 52 Hill-type musculotendon units acting about the hip and the knee. A computed muscle control algorithm was used to determine muscle excitation patterns that drove the limb to track measured hip and knee sagittal plane kinematics, with measured ground reactions applied to the limb. RESULTS The hamstrings lengthened under load from 50% to 90% of the gait cycle (swing) and then shortened under load from late swing through stance. Although peak hamstring stretch was invariant with speed, lateral hamstring (biceps femoris) loading increased significantly with speed and was greater during swing than stance at the fastest speed. The biarticular hamstrings performed negative work on the system only during swing phase, with the amount of negative work increased significantly with speed. CONCLUSION We concluded that the large inertial loads during high-speed running appear to make the hamstrings most susceptible to injury during swing phase. This information is relevant for scientifically establishing muscle injury prevention and rehabilitation programs.

Increasing Running Step Rate Reduces Patellofemoral Joint Forces

PURPOSE Increasing step rate has been shown to elicit changes in joint kinematics and kinetics during running, and it has been suggested as a possible rehabilitation strategy for runners with patellofemoral pain. The purpose of this study was to determine how altering step rate affects internal muscle forces and patellofemoral joint loads, and then to determine what kinematic and kinetic factors best predict changes in joint loading. METHODS We recorded whole body kinematics of 30 healthy adults running on an instrumented treadmill at three step rate conditions (90%, 100%, and 110% of preferred step rate). We then used a 3-D lower extremity musculoskeletal model to estimate muscle, patellar tendon, and patellofemoral joint forces throughout the running gait cycles. In addition, linear regression analysis allowed us to ascertain the relative influence of limb posture and external loads on patellofemoral joint force. RESULTS Increasing step rate to 110% of the preferred reduced peak patellofemoral joint force by 14%. Peak muscle forces were also altered as a result of the increased step rate with hip, knee, and ankle extensor forces, and hip abductor forces all reduced in midstance. Compared with the 90% step rate condition, there was a concomitant increase in peak rectus femoris and hamstring loads during early and late swing, respectively, at higher step rates. Peak stance phase knee flexion decreased with increasing step rate and was found to be the most important predictor of the reduction in patellofemoral joint loading. CONCLUSION Increasing step rate is an effective strategy to reduce patellofemoral joint forces and could be effective in modulating biomechanical factors that can contribute to patellofemoral pain.

Changes in Muscle Activation Patterns when Running Step Rate is Increased

Running with a step rate 5-10% greater than ones preferred can substantially reduce lower extremity joint moments and powers, and has been suggested as a possible strategy to aid in running injury management. The purpose of this study was to examine how neuromuscular activity changes with an increase in step rate during running. Forty-five injury-free, recreational runners participated in this study. Three-dimensional motion, ground reaction forces, and electromyography (EMG) of 8 muscles (rectus femoris, vastus lateralis, medial gastrocnemius, tibialis anterior, medial and lateral hamstrings, and gluteus medius and maximus) were recorded as each subject ran at their preferred speed for three different step rate conditions: preferred, +5% and +10% of preferred. Outcome measures included mean normalized EMG activity for each muscle at specific periods during the gait cycle. Muscle activities were found to predominantly increase during late swing, with no significant change in activities during the loading response. This increased muscle activity in anticipation of foot-ground contact likely alters the landing posture of the limb and the subsequent negative work performed by the joints during stance phase. Further, the increased activity observed in the gluteus maximus and medius suggests running with a greater step rate may have therapeutic benefits to those with anterior knee pain.

Neuromusculoskeletal models provide insights into the mechanisms and rehabilitation of hamstring strains.

Neuromusculoskeletal models are used to investigate hamstring mechanics during sprinting. We show that peak hamstring stretch occurs during late swing phase and is invariant with speed, but does depend on tendon compliance and the action of other muscles in the lumbopelvic region. The insights gained are relevant for improving the scientific basis of hamstring strain injury prevention and rehabilitation programs.

Electromyography activity across gait and incline: The impact of muscular activity on human morphology

The study of human evolution depends upon a fair assessment of the ability of hominin individuals to gain access to necessary resources. We expect that the morphology of extant and extinct populations represents a successful locomotory system that allowed individuals to move across the environment gaining access to food, water, and mates while still maintaining excess energy to allocate to reproduction. Our assessment of locomotor morphology must then incorporate tests of fitness within realistic environments--environments that themselves vary in terrain and whose negotiation requires a variety of gait and speeds. This study assesses muscular activity (measured as the integrated signal from surface electromyography) of seven thigh and hip muscle groups during walking and running across a wide range of speeds and inclines to systematically assess the role that morphology can play in minimizing muscular activity and thus energy expenditure. Our data suggest that humans are better adapted to walking than running at any slope, as evidenced by small confidence intervals and even trends across speed and incline. We find that while increasing task intensity unsurprisingly increases muscular activity in the lower limb, individuals with longer limbs show significantly reduced activity during both walking and running, especially in the hip adductors, gluteus maximus, and hamstring muscles. People with a broader pelvis show significantly reduced activity in the hip adductor and hamstring muscles while walking.

Hamstrings are most susceptible to injury during the late swing phase of sprinting

It is well recognised that the hamstrings are susceptible to acute strain injury during high-speed running. However, the particular phase of the sprinting gait cycle at which hamstring injury occurs remains a debated topic. Video footage and athlete anecdotes have contributed to the discussion, but do not provide sufficient temporal resolution to fully answer the question. In this paper, we briefly review: (A) biomechanical data obtained from healthy athletes; (B) case studies of injuries during biomechanical experiments; and (C) clinical outcomes from intervention studies. We believe all of these support the premise that late swing phase is the likely time when the biarticular hamstrings are most vulnerable to injury. Early …