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.
Peter Georgilopoulos says
Dear Sports Physiotherapist,
Thank you for the interest you have shown in our study . I presented an expanded format at the APA Conference on 28 th Oct 2011 incorporating a follow up study which looked at the effect of doubling the intervention time to 6 minutes . The results were very interesting showing that although the static stretching group results over 6 minutes showed significant gains [compared to the non significant results over 3 minute ] , the overall results were still well below the outcomes [ both significant ] of the 3 min. and 6 min. Z- joint mobilisation group. Also interesting was that the outcome of the longer Z- joint mobilisation group for 6 min. was not greater than the outcome for 3 min. In other words the effect of Z- joint mobilisation appears to be considerably more effective in delivering posterior thigh flexibility compared to static stretching over a similar intervention period but does not continue to improve beyond the shorter intervention period.
In answer [ partly ] to limitations listed above :
 “The effect of stretching neural structures on grade 1 hamstring injuries” Kornberg C, Lew PJ. Orthop Sport Phys Ther 1989 :10 481-487 goes some way to linking dural techiques with increased positive outcomes in treatment of hamstring strains. Physically achieving an increase in dural flexibility has now been answered by our study to some degree and will be investigated further next year.
Looking at longevity of the effect of stretching vs. Z- joint mobilisation will certainly be another follow up study. I might point you in the direction of two excellent studies by the same key author [Magnusson S et al . Biomechanical responses to repeated stretches in human hamstring muscle in vivo. Am Jn Sports Med 1996: 24 : 622- 682. & Magnusson S et al . Passive energy absorbtion by human muscle – tendon unit is unaffected by increase in intramuscular temperature. Jn App Physiol.2000:88: 125- 128.
 The final point is looking at the reasons behind why a spread of 6 segmental levels has been undertaken [ from T12 to L5 inclusive] in preference to anatomical nerve root segments to the hamstrings . The answer is [a] we required uniformity in intervention time between stretching and mobilisation groups for direct analysis and comparison and [b] we referenced our segental selection based on a paper by Gabbe B et al ” Risk factors for hamstring injuries in community level Australian football. Br Jn Sports Med 2005 Feb: 39 : 106- 110 in which they identified that decreased quadriceps flexibility was one of 2 risk factors [ the other being age >23 years] .
As a pioneering study we certainly did not wish to assume what the mechanisms of posterior thigh limitation might be prior to examining all possibilities . Once again further research next year will look at specific segental levels .
Your members may be interested to know that these findings were presented as part of a 2 hour [!!] presentation by me for the Olympic Solidarity Symposium on behalf of the IOC ay UQ on Sunday 27 th Nov 2011. Most speakers were former Olympic team representatives and included Ross Smith , David Zuker , Craig Allingham , Greg Craig amongst others. Convenor was Mark Brown and I can forward his details if interested .
Many thanks once again ,
The Sports Physiotherapist says
Thank you so much for your reply Peter!! It is great to hear from one of the study’s authors about the thinking and assumptions made prior to this study. I cannot wait to see the future research you have planned around this exciting realm of clinical practice. I’d also like to personally thank you for your contribution to all of our clinical practice.
john power says
For all of my buttock, hamstring and calf pain/injury clients, I routinely assess the SI joint and lumbar spine via neurodynamic tests. I have had good results with runners w/calf pain by including neurodynamic mobilizations. Addressing the lumbar spine is essential. I do not manipulate the spine though I often find poor core control as a significant factor.
Julie campbell says
I find that another factor to consider when treating hamstring strains and attempting to increase the rom of the slr is to address piriformis tightness and it’s relationship to the sciatic nerve. Dry needling and/or soft tissue release of piriformis will often result in an increase of slr and a reduction of posterior thigh pain. The other technique I find clinically effective is a lumbar rotation mobilization combined with a neural mobilization- best left until symptoms are non-irritable to regain the last degrees of range. I always follow up with strengthening and endurance into new rom.
The Sports Physiotherapist says
Great intervention ideas Julie! Thanks for your input and contribution!