Rehabilitation from injuries with help from Pilates is something often needed by my partner, Michael, when he arrives home following cycling accidents and surfing incidents. Our families are often the best sources of new material when it comes to working through injuries and rehabilitation issues. My most recent opportunity for Pilates growth involved Michael experiencing a Grade 2 hamstring injury when surfing.
This article is about working with the more mature weekend warrior suffering a hamstring injury. There is a lot of material about working with hamstring injuries, particularly for footballers of various codes, but working with someone in his early 60s is very different to working with an elite athlete in their teens or twenties. I certainly hope that you don’t hear the hamstring snap in a class setting, but you may see a client coming to see you after they have done this. You may also be seeing some passive overstretch hamstring injuries or tendinopathies, especially in dancers or after some barre classes, so it is best to be prepared.
Whenever you deal with an injury, whether it be a hamstring, shoulder or neck, it is important to understand the individual muscles and joints and their functional role in whole-body movement. When you understand these patterns and your client’s activities, the development of a movement plan can be quite simple. It’s getting the load right that is the challenge.
The Role Of Hamstrings
Hamstrings are part of the deep longitudinal sling. They work in conjunction with the tibialis anterior muscles for dorsiflexion and the erector spine muscles for a thoracic extension.
The specific joint movements facilitated by the hamstrings include hip extension and knee flexion in various stages of gait.
Understanding these slings and joint patterns helps understand what function has been lost because of the injury and what can be done to support functional return. In the case of hamstring injuries, the exercise choices require a focus on return to walking, running and spinal extension. The grading of your client’s program depends on the mechanism of injury stages of healing, their particular goals and their condition before the injury.
Mutually respectful work with a physiotherapist is also essential.
Mechanism Of Hamstring Injury
There are a few different ways you can damage a hamstring muscle, including:
// active overstretch and
// passive overstretch.
Each of these is more likely to affect one of the different muscle in the hamstring group.
A trauma muscle injury may be contact trauma or surgery. About six years earlier Michael had contact trauma injury to his hamstring when he had a bicycle accident. In that case, there was an avulsion fracture of the ischial tuberosity, resulting in his hamstring being torn. Notably, six years later this was the same hamstring damaged during his surf incident. Once a hamstring has been damaged there is a vulnerability to future tears. Direct trauma can also happen as a result of surgeries, e.g. when an anterior cruciate ligament (ACL) is reconstructed and part of a hamstring tendon is removed to recreate the ligament.
Active overstretch is also known as a ‘deceleration’ injury, because the hamstring is actively slowing the movement of the leg. For example, when the hamstring muscle is working eccentrically but is overcome by the stretching force applied to it and forcibly lengthened. This type of injury generally involves the biceps femoris during high-speed running, and it is believed to occur during the terminal swing phase of the gait cycle as the hamstrings decelerate the leg in preparation for foot contact. It is usually accompanied by the sudden onset of pain and an inability to continue the activity. This is the type of injury Michael experienced when surfing, when his surfboard unexpectedly stalled during a turn, resulting in rapid deceleration and active overstretch.
Passive overstretch occurs when a stretch force is applied to the hamstring muscle, with an injury occurring at the limit of range. Commonly seen amongst footballers kicking, or dancers, and generally involves the free tendon of semimembranosus and amongst dancers was also noted to involve quadratus femoris. Even if the force is applied slowly (as in a dancer stretching), there may be a pop associated with the injury. Symptoms may not develop for some hours, or only slowly over time, and may not be more than mild discomfort and dysfunction.
The Location Of The Hamstring Strain
The active overstretch or running injury tends to be at the musculo-tendinous junction of the quite lengthy intramuscular biceps femoris tendon and adjacent muscle.
The closer the maximally tender point is to the buttock (think close to the ischial tuberosity), the more likely the injury is to involve tendon tissue and the slower the rehabilitation. Any of the mechanisms of injury can lead to tendon complication it is most likely to be coming from a passive overstretch injury and can have a much longer recovery program; at least 6 weeks and often 30-76 weeks. I have worked with a few ballerinas who have struggled with this recovery process. I would be particularly careful with this type of injury if you teach barre.
Remember, it is very important that your physiotherapist clears other options – especially when there was not an obvious ‘mechanism’ of injury.
The Healing Phases
Stage one: The destruction phase is the first day or so after the injury. This is when you will see the start of bruising (haematoma) and necrosis of the myofibers which induce an inflammatory cell reaction lasting for the first few days following injury. In higher grade injuries the bruising will come out over the course of a few weeks.
At this stage the focus is on pain management and avoiding stretching and sitting.
Stage two: Repair phase begins a few days after injury and peaks around 2 weeks post injury. It allows regeneration of the myofibers and simultaneous production of a type of collagen for early scar tissue. This is when your client should be doing some small movements at home, under the guidance of their physiotherapist. It is good to get a list of their exercises from this stage, because you will see how they inform your exercise progressions when the client comes back to the studio.
If there is a ‘passive stretch’ injury the functional loss for the person will be in flexibility, then active rather than passive stretching is ideal. Active exercises would be those designed to increase range of motion (hip flexion with different extension angles at the knee). For this type of injury it’s recommended to consider foam roller or trigger point work rather than stretching to avoid tensile and compression load on the tendon.
When working with hamstring injuries it is important to remember that the muscle attaches to the pelvis and therefore will impact on lumbo-pelvic control/ stability. This means you will need to add lumbo pelvic focus to your class through low load and low speed and NOT in the same plane in which the hamstring injury occurred. In other words if the injury occurred in the sagittal plane you are going to start your focus on strengthening the pelvis in the coronal plane e.g. clams.
Progression of this work would focus on speed, intensity and into the sagittal plane. Gentle, pain free, eccentrically focussed exercises (what Pilates is famous for), to accelerate recovery (this is not quicker healing, but functioning at a higher level with less pain). It’s important to note that whilst the client might be feeling quite good at this stage, healing is still in the early days and is vulnerable to further injury.
For example, at this stage the client will be doing things like:
- Towel leg slides ( we know this from our Pre-Pilates work)
- Ball-supported leg slides and side to side
- Standing towel leg extensions
- Wall slide/ mini squats (with a quad focus)
- Some spinal mobility
You are not wanting to have load or resistance on the affected areas at this stage because the muscle fibres are not able to withstand forces, and could easily tear and prolong recovery.
Stage three: Remodelling phase begins 2-3 weeks following injury and involves the production of scar tissue, regenerated myofibres are maturing, scar tissue is re-organised and contracts, and the functional capacity of the muscle recovers.
The client should start walking without pain and adding in some work on a stationery exercise bike at around week three. At around week 4 and definitely by week 6 your client will be coming back in a private or semi-private setting. It will probably be around week 12 where your client will be returning to sport, but I would still be taking it moderately careful at this stage building up strength and endurance particularly in your older clients, who in general will have slower healing times. With high level athletes there is often a much faster return to sport, and they are managed by quite the team of health professionals.
Exercise choices include:
First 8 weeks
Starting at no resistance, progressing to some very light resistance with a lot of quad focus to this stage as part of the home program, building in resistance and load on the exercises given during stage 2.
Specific exercises for hamstring
- Seated press outs on reformer or CoreAlign
- Standing leg work
- Spinal rotation and movement
- Ankle movement focus using jump board
- Mat bird dog progressing from keeping the foot on the ground to extending and lifting the leg up.
- Thoracic mobility (think deep longitudinal sling) and how you may cue from dorsiflexion.
Stage four: Sports or activity specific. In the case of ‘active overstretch’ injury the exercise program is gradually progressed to high level agility and sport specific drills, high level eccentric work, possibly including Nordic curls The recovery program also progresses to include high speed eccentric conditioning (sprinting or jump board work), as well as emphasising varying trunk movements during running or on the CoreAlign (e.g. upright posture, forward flexed, forward flexed and rotated).
For the ‘passive stretch’ injury, return to activity will be slow, with a high risk of recurrence. It is important for your client to understand gradual pacing will improve their recovery and reduction of re-injury. With this type of injury, tendon rehabilitation is likely to be part of the plan. Continued graduated increase in both tensile and compressive forces is essential for hamstring recovery.
Some exercises that may be appropriate in the rehabilitation of hamstring injuries are the following. These exercises can also be considered very relevant as part of the hamstring preparation work for prevention of injuries.
To better understand the gait cycle and how to manage lower limb injuries try our Hip and Femur online course
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Cook JL, Purdam CR Is tendon pathology a continuum? A pathology model to explain the clinical presentation of load-induced tendinopathy. Br J Sports Med. 2009 Jun;43(6):409-16. doi: 10.1136/bjsm.2008.051193. Epub 2008 Sep 23.
Verrall GM, Slavotinek JP, Barnes PG. The effect of sports specific training on reducing the incidence of hamstring injuries in professional Australian Rules football players. Br J Sports Med. 2005;39:363–368
Zbrojkiewicz D, Vertullo C, Grayson JE. (2018) Increasing rates of anterior cruciate ligament reconstruction in young Australians, 2000-2015ha