Rehabilitation for hamstring injuries

Hamstring injuries are a common musculoskeletal disorder, particularly amongst athletes. Many factors have been associated with these injuries including motor control and strength, soft tissue length and postural alignment. Well established rehabilitation protocols are commonly used in the treatment of this condition, but their effectiveness remains questionable.

To evaluate the effectiveness of all rehabilitation strategies employed to promote the return to full strength, range of movement and function of those individuals presenting with all forms of hamstring injury, regardless of site, severity, onset or level of chronicity.

We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register (to January 2006), CENTRAL (The Cochrane Library 2006, Issue 1), MEDLINE, EMBASE, PEDro - The Physiotherapy Evidence Database, CINAHL, AMED, SPORTDiscus and reference lists of articles. Date of last search: February 2006. No language restrictions were applied.

Selected studies were randomised controlled trials or randomised comparative trials, investigating the effect of at least one rehabilitation strategy, in isolation or combination with another, compared to another strategy or control, performed on individuals presenting with hamstring injuries.

Two review authors performed study selection. Three review authors performed data extraction and methodological quality assessment. Any disagreement was resolved by discussion.

Three trials were included in the review. The main results present limited evidence over a range of techniques and patient groups. There was no trial of intervention versus rest. Only two small trials compared times to return to normal function, and definition of this outcome varied between studies. The first trial, involving 80 athletes, suggested stretching four times a day instead of just once and resulted in a statistically significant reduction in time to return to normal function (mean difference (MD) -1.8 days, 95% confidence interval (CI) -2.15 to -1.45, P < 0.001). The second trial, with 24 participants from a diverse sporting background, found that progressive agility and trunk stabilization exercises and icing did not achieve a statistically significant reduction in time to return to full function when compared to stretching and progressive resistance exercises and icing (MD -14.5 days, 95% CI -30.64 to 1.64, P = 0.08). The third trial, conducted with 20 non-athletes, suggests there was no evidence of effect with manual therapy on soft tissue length (MD 10.4 degrees, 95% CI -3.19 to 23.99 in favour of manual therapy, P = 0.13), on hamstring muscle peak torque (MD -0.7 foot-pounds, 95% CI -18.45 to 17.05 in favour of control, P = 0.94), or on quadriceps femoris muscle peak torque (MD -22.1 foot-pounds, 95% CI -59.00 to 14.80 in favour of control, P = 0.24) following a single treatment.

There is limited evidence to suggest that rate of recovery can be increased with an increased daily frequency of hamstring stretching exercises. Consideration should be given to the lumbar spine, sacroiliac and pelvic alignment and postural control mechanisms when managing hamstring injuries. Lumbar stability and pelvic motor control may also be factors in reducing the rate of recurrence of hamstring injury. Until further evidence is available, current practice and widely published rehabilitation protocols cannot either be supported or refuted.