{"id":6544,"date":"2015-11-22T07:47:30","date_gmt":"2015-11-22T06:47:30","guid":{"rendered":"http:\/\/stg-blogs.bmj.com\/bjsm\/?p=6544"},"modified":"2015-11-22T08:02:43","modified_gmt":"2015-11-22T07:02:43","slug":"hamstring-rehabilitation-criteria-based-progression-protocol-and-clinical-predictors-for-return-to-play","status":"publish","type":"post","link":"https:\/\/stg-blogs.bmj.com\/bjsm\/2015\/11\/22\/hamstring-rehabilitation-criteria-based-progression-protocol-and-clinical-predictors-for-return-to-play\/","title":{"rendered":"Hamstring Rehabilitation: Criteria based progression protocol and clinical predictors for return to play"},"content":{"rendered":"<p><strong>By Nicol van Dyk<\/strong>, Physiotherapist, Rehabilitation Department, Aspetar Orthopaedic and Sports Medicine Hospital and;<\/p>\n<p><strong>Rod Whiteley<\/strong>, Assistant Director, Rehabilitation Department, Aspetar Orthopaedic and Sports Medicine Hospital<\/p>\n<p>&nbsp;<\/p>\n<p><em>(presented at the ASICS Sports Medicine Australia conference 2015 \u2013 find all the slides <\/em><a href=\"http:\/\/www.slideshare.net\/NicolvanDyk\/sma-2015-hamstring-symposium\"><em>here<\/em><\/a><em>)<\/em><\/p>\n<p><strong><em>\u201cIt\u2019s tough to make predictions, especially about the future.\u201d Yogi Berra<\/em><\/strong><\/p>\n<p>It is still one of the most difficult questions clinicians have to answer: \u201cWhen can I play again?\u201d\u00a0 Not only the player, but also the coach and\/or family members will push you for an answer.\u00a0 And then we all rub our crystal ball, get out the magic wand, and give them something we feel is sort of close to the mark.\u00a0 But in reality, we still have very little on which to base our predictions.\u00a0 Most of the time we\u2019re guessing.\u00a0 (Educated guessing maybe, but guessing nonetheless.) But before that happens, we first have to get them through the rehab.\u00a0 Rehabilitation has moved away from time, and grown into criteria-based progression \u2013 the paradigm has begun to shift.<\/p>\n<p>There are many excellent rehabilitation protocols of course, and you can find some of them in landmark papers such as <a href=\"https:\/\/app.box.com\/s\/go3npaljjxfah7r5jsghwdy7szw36e4z\">Sherry and Best 2004<\/a>. \u00a0<a href=\"http:\/\/bjsm.bmj.com\/content\/49\/18\/1197.abstract?sid=d087dfb8-1042-40cc-943b-54c413e8980b\">Reurink et al<\/a> published an updated SR investigating different interventions for hamstring strain injury rehabilitation. Not wanting to be left out, we developed a hamstring rehabilitation protocol at the <a href=\"http:\/\/www.aspetar.com\/\">Aspetar Orthopaedic and Sports Medicine Hospital<\/a>, based on available literature and clinical experience (that magic combination that doesn\u2019t always like each other, but oh how sweet when they do).\u00a0 Our initial assessment and treatment includes elements that will form part of most protocols.\u00a0 <strong>So I will focus on three critical elements that we were able to identify:<\/strong><\/p>\n<ul>\n<li>The most important measurement is strength, especially outer range strength<\/li>\n<li>A running progression protocol that includes volume, intensity, mechanics, and is sport specific<\/li>\n<li>Criteria based progression between different stages in the rehabilitation<\/li>\n<\/ul>\n<p><strong>First things first \u2013 measure the strength.<\/strong><\/p>\n<p>With the use of standardized measurement procedure using hand held dynamometers, we measure inner, mid, and outer range strength of the injured and uninjured hamstring muscles.\u00a0 The most valuable measurement has been the outer range strength, as this has tracked well with return to play.\u00a0 In other words, by the time the player was discharged, he had regained his outer range strength fully when compared to the uninjured side.\u00a0 Mid-range strength was also tracking well, while inner range strength normalized much more quickly \u2013 often as fast as a few days, so it was less helpful to measure if your aim was to get a \u201cprogress bar\u201d for this athlete\u2019s rehabilitation. (<a href=\"https:\/\/onedrive.live.com\/redir?page=view&amp;resid=4534E0D33770AD0C!48190&amp;authkey=!AG7BpQfSpHfgfUw\">Video of how to do this testing<\/a>).\u00a0 We were fortunate to see patients 5 days a week, but if that is not possible, use the outer range strength measurement to keep track of the progression.<\/p>\n<p><img loading=\"lazy\" decoding=\"async\" class=\"aligncenter wp-image-6546\" src=\"https:\/\/stg-blogs.bmj.com\/bjsm\/files\/2015\/11\/figure-1-hamstring-15.11.181.jpg\" alt=\"figure 1 hamstring 15.11.18\" width=\"491\" height=\"454\" srcset=\"https:\/\/stg-blogs.bmj.com\/bjsm\/files\/2015\/11\/figure-1-hamstring-15.11.181.jpg 616w, https:\/\/stg-blogs.bmj.com\/bjsm\/files\/2015\/11\/figure-1-hamstring-15.11.181-300x278.jpg 300w\" sizes=\"auto, (max-width: 491px) 100vw, 491px\" \/><br \/>\nIn our experience, nearly all of the hamstring injuries were due to running. If you see dancers (and maybe martial artists) you probably need to take our advice with a grain of salt. We agree with Askling that stretch type injuries are a different beast, but we can\u2019t help you there as we really hardly ever see these. However for our patients, all rehab protocols must include running. Specifically, running as close as you can get to what would be required of the player and their sport.\u00a0 At our facility, players would typically run from stage 2 and run 3 sets of 4 laps on an indoor track (8 \u201csprints\u201d) approximating 700m.\u00a0 We asked the player to rate their running on a scale from\u00a0 0-100%, and timed their running. \u00a0This was also an excellent way to keep track of their progression (another great tip if you don\u2019t have running facilities or can\u2019t see your patient daily).\u00a0 Finally, in stage 3 we included direction changes by modifying the T-drill a bit (in our version, keep running forwards, but with direction changes to run around the markers).<\/p>\n<figure id=\"attachment_6547\" aria-describedby=\"caption-attachment-6547\" style=\"width: 435px\" class=\"wp-caption aligncenter\"><img loading=\"lazy\" decoding=\"async\" class=\" wp-image-6547\" src=\"https:\/\/stg-blogs.bmj.com\/bjsm\/files\/2015\/11\/figure-2-hamstring-15.11.18.png\" alt=\"Modified T-drill to facilitate direction change\" width=\"435\" height=\"326\" srcset=\"https:\/\/stg-blogs.bmj.com\/bjsm\/files\/2015\/11\/figure-2-hamstring-15.11.18.png 480w, https:\/\/stg-blogs.bmj.com\/bjsm\/files\/2015\/11\/figure-2-hamstring-15.11.18-300x225.png 300w\" sizes=\"auto, (max-width: 435px) 100vw, 435px\" \/><figcaption id=\"caption-attachment-6547\" class=\"wp-caption-text\">Modified T-drill to facilitate direction change<\/figcaption><\/figure>\n<p>When the player was able to run at 100%, and do direction changes at 100%, he\/she was allowed to go out on the field and perform sport specific rehabilitation with our sports rehabilitators.\u00a0 After they successfully complete 3 sessions, each one harder than the last, we performed some discharge tests (including isokinetic testing) and recommendations to the club to allow a gradual return to play.<\/p>\n<p>Here is our criteria based progression algorithm:<\/p>\n<p><img loading=\"lazy\" decoding=\"async\" class=\"aligncenter wp-image-6548\" src=\"https:\/\/stg-blogs.bmj.com\/bjsm\/files\/2015\/11\/hamstring-figure-3-11.18.png\" alt=\"hamstring figure 3 11.18\" width=\"471\" height=\"301\" srcset=\"https:\/\/stg-blogs.bmj.com\/bjsm\/files\/2015\/11\/hamstring-figure-3-11.18.png 1341w, https:\/\/stg-blogs.bmj.com\/bjsm\/files\/2015\/11\/hamstring-figure-3-11.18-300x192.png 300w\" sizes=\"auto, (max-width: 471px) 100vw, 471px\" \/><\/p>\n<p>And now, the magic question \u2013 when are they ready?\u00a0 Considering the outcome reported in the literature, it varies considerably.\u00a0 One thing we do know is that MRI parameters cannot help us to determine return to play, and adds no value above our clinical assessment.\u00a0 See this <a href=\"http:\/\/bjsm.bmj.com\/content\/early\/2015\/09\/09\/bjsports-2015-094892.abstract?sid=4b6e6572-6e6b-4150-8cb1-f29b8ed659c4\">article<\/a> by <a href=\"https:\/\/twitter.com\/arnlaugw?lang=en\">Arnlaug Wangensteen<\/a>, who has contributed enormously to our rehabilitation programme.<\/p>\n<p><strong>So why is the outcome for return to sport so variable?<\/strong> Here\u2019s a thought &#8211; perhaps because everyone is employing \u201cconventional rehab\u201d for their control groups, but no one knows what that is?\u00a0 In a soon to be published article in BJSM by Philipp Jacobsen, with some excellent work by co-author <a href=\"https:\/\/twitter.com\/RodWhiteley?lang=en\">Rod Whiteley<\/a>, they have investigated the things that we measure, and found some clinical predictors of return to play.\u00a0 So you will have to wait for the full length version to appear in an upcoming addition of BJSM, but here is the teaser:<\/p>\n<p>Using a regression analysis, a combination of features you can easily measure in your clinical examination on day 1 and day 7 the week 1 examination could predict return to play within a 10 day window, explaining 97% of the variance!\u00a0 And here are the more important parameters to look out for:<\/p>\n<ul>\n<li>Length of pain on palpation<\/li>\n<li>Single leg bridge<\/li>\n<li>Hamstring strength (compared to the uninjured side) and whether it is painful or not<\/li>\n<li>Change in outer range strength over the week<\/li>\n<\/ul>\n<p>Now, the data is over-fitted (which means it is too good to be true, and won\u2019t stand up when they finish their replication study that\u2019s nearly half way done), but even with that said, how good is a 10 day window?\u00a0 The coach, the player, the media \u2013 they want to know if the player will be ready for the final, and maybe now we can be confident \u00b1 5 days.\u00a0 That is a pretty specific time point, and the reality is, even when I am using an equation set up to win, the best I can do is \u201cUh, yes, plus or minus 5 days.\u201d\u00a0 Is that good enough? I have a sneaky suspicion that it will still not satisfy.\u00a0 But for now, it\u2019s the best we can do!<\/p>\n<p>So the next time you\u2019re faced with the all impossible question, perhaps you have some better answers.\u00a0 Not easy answers, but we can say it will take about 3 weeks (give or take 5 days); we have a really good rehabilitation plan, which is measuring what you can do and your progression is based on that; and we will keep track of your progression based on what you need to return to play.<\/p>\n<p>That\u2019s probably as good as it gets!<\/p>\n<p>&nbsp;<!--TrendMD v2.4.8--><\/p>\n","protected":false},"excerpt":{"rendered":"<p>By Nicol van Dyk, Physiotherapist, Rehabilitation Department, Aspetar Orthopaedic and Sports Medicine Hospital and; Rod Whiteley, Assistant Director, Rehabilitation Department, Aspetar Orthopaedic and Sports Medicine Hospital &nbsp; (presented at the ASICS Sports Medicine Australia conference 2015 \u2013 find all the slides here) \u201cIt\u2019s tough to make predictions, especially about the future.\u201d Yogi Berra It is [&#8230;]<\/p>\n<p><a class=\"btn btn-secondary understrap-read-more-link\" href=\"https:\/\/stg-blogs.bmj.com\/bjsm\/2015\/11\/22\/hamstring-rehabilitation-criteria-based-progression-protocol-and-clinical-predictors-for-return-to-play\/\">Read More&#8230;<\/a><\/p>\n","protected":false},"author":1,"featured_media":0,"comment_status":"open","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":{"_jetpack_memberships_contains_paid_content":false,"footnotes":""},"categories":[1],"tags":[1623,2903,1502],"class_list":["post-6544","post","type-post","status-publish","format-standard","hentry","category-uncategorized","tag-hamstring","tag-return-to-play","tag-running"],"jetpack_featured_media_url":"","jetpack_sharing_enabled":true,"_links":{"self":[{"href":"https:\/\/stg-blogs.bmj.com\/bjsm\/wp-json\/wp\/v2\/posts\/6544","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/stg-blogs.bmj.com\/bjsm\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/stg-blogs.bmj.com\/bjsm\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/stg-blogs.bmj.com\/bjsm\/wp-json\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/stg-blogs.bmj.com\/bjsm\/wp-json\/wp\/v2\/comments?post=6544"}],"version-history":[{"count":0,"href":"https:\/\/stg-blogs.bmj.com\/bjsm\/wp-json\/wp\/v2\/posts\/6544\/revisions"}],"wp:attachment":[{"href":"https:\/\/stg-blogs.bmj.com\/bjsm\/wp-json\/wp\/v2\/media?parent=6544"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/stg-blogs.bmj.com\/bjsm\/wp-json\/wp\/v2\/categories?post=6544"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/stg-blogs.bmj.com\/bjsm\/wp-json\/wp\/v2\/tags?post=6544"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}