As sports physiotherapists we regularly assess and treat hamstring strains, sometimes on a daily basis! Hawkins et al. (2001) showed that hamstring injuries accounted for approximately 12% of football injuries, and thus are extremely common. Given their frequency, hamstring injuries have been discussed commonly on this site, and the articles have included:
- Clinical Predictors of Return to Play Timeframes Following Hamstring Injury
- Evidence Based Interventions to Prevent Hamstring Injuries
However, to date, we have not paid much attention to the often recommended intervention of spinal manual therapy and its role in the evidence based management of hamstring strains. Let’s take a look at a clinical case.
A Troublesome Clinical Case
We will often encounter the troublesome hamstring case. Take a low grade injury that you choose to manage with soft tissue techniques, a comprehensive program of strengthening and stretching exercises, neuromuscular control interventions and possibly even EPA. However, after some time they still do not reach full improvement, and still can’t quite “stretch out”. Or worse yet, return to play and have an injury recurrence.
Agh, what’s gone wrong? You may say; but I did all the right things! Well, new research may suggest that there may have been one missing piece of that puzzle.
A Role for Lumbar Spine Mobilisations for Hamstring Strains?
It is conceivable that lumbar spine mobilisations may be useful in the management of hamstring strains. It is generally agree that gold standard management of hamstring injuries includes restoration of normal biomechanics and movement patterns (Sherry and Best, 2004; Mason and Dickens, 2007). Frequently, patients that have suffered a hamstring injury present with adverse neuro-dynamics. Turl and George (1998) suggested that this can influence both hamstring muscle activity as well as lumbopelvic biomechanics. Thus, restoration of adverse neurodynamics should be considered an integral component of hamstring injury management.
Szelzak et al. (2011) have just published a randomised controlled trial to investigate the impact of unilateral z-joint mobilisations for improving posterior chain neurodynamics. They randomised 36 healthy participants into 3 groups:
- Control Group: no intervention.
- Mobilisation Group: 3 minutes of ipsilateral grade III PA unilateral z-joint mobilisations (30 seconds per level T12/L1 – L5/S1)
- Stretching Group: a 3 minute passive therapist assisted straight-leg raise (SLR) stretch at R1.
They found some interesting results! The only group with a statistically significant response to the intervention was the mobilisation group, which improved straight-leg raise by an average of 8.5º. Whereas, the other 2 groups (control and stretching) did not improve significantly post-intervention.
Limitations of this Research
As usual there a few limitations to this research, and these must always be considered prior to applying the findings to your clinical practice. The most obvious are:
- Healthy participants are used. Thus, it is unclear whether an injured patient, i.e. one with a hamstring strain, would respond similarly.
- The effects are evaluated immediately and there is no longer term follow-up. Thus, we cannot appreciate how long the treatment effects last.
- The clinician mobilises all levels of the lumbar spine, regardless of objective findings. Future research should evaluate the most effective levels for mobilisation, and how this corresponds to objective clinical findings of hypomobility/tenderness etc.
Take Home Messages
- Restoration of normal neurodynamics and biomechanics is essential for optimal function following hamstring strain
- Unilateral z-joint mobilisations have been shown to be effective in immediately improving posterior chain neurodynamics
- This treatment may be effective in the management of hamstring strains
What Are Your Thoughts?
What is your experience with manual therapy interventions for hamstring strains? Do you love them or hate them and most of all find them clinically effective? I would love to hear your thoughts! Be sure to let me know in the comments or catch me on Facebook or Twitter
Photo Credit: Ed Yourdon
Hawkins RD, Hulse MA, Wilkinson C, Hodson A, Gibson M. The association football medical research programme: an audit of injuries in professional football. Br J Sports Med 2001;35:43–7
Mason DL, Dickens VA, Vail A. Rehabilitation for hamstring injuries. Cochrane Database System Rev 2007;1:CD004575.
Sherry MA, Best TM. A comparison of two rehabilitation programs in the treatment of acute hamstring strains. Journal of Orthopaedic & Sports Physical Therapy 2004;34:116e25.
Szlezak AM, Georgilopoulos P, Bullock-Saxton JE, Steele MC. The immediate effect of unilateral lumbar Z-joint mobilisation on posterior chain neurodynamics: A randomised controlled study. Manual Therapy 2011;16(6):609-613
Turl SE, George K. Adverse neural tension: a factor in repetitive hamstring strain? Journal of Orthopaedic & Sports Physical Therapy 1998;27:16e21.