If only I knew…
What to do with my hamstring pull.
A friendly medical chronicle.
By Marie-Catherine Bruno, BScPT, Cped(C).
Of all the muscles a runner can pull, the hamstrings is definitely one of the most frequently reported. There seem to be a plethora of reasons why, but although we know and understand the causes of it, runners still get hamstring pulls everyday. We will look at those causes so that you can determine whether you are at risk, and then look at the treatment for those who were unfortunate.
Hamstring Pull Risk factors
The hamstrings is a group of muscles (biceps femoris, semitendinosis, semimembranosis) that attaches on your pelvis, on a part called the ischial tuberosity (the bone you sit on). The different muscles run on the back of your thigh and attach on either side of your knee (biceps femoris attaches on the external side of your knee, on the head of the fibula, and the two others – semimembranosis and semitendinosis – attach on the other side of your knee, the internal side). Their main function is to bend the knee, but they also assist in extending the hip (kicking the thigh back). They come into play on every step you take when you are running, and they work even harder on hill climbs or sprints. Most ruptures actually occur during a sprint or a major hill climb, and affect the tendon, as opposed to the muscle bulk.
There are 3 degrees of injury for a hamstring pull (it is actually the scale used for any muscle pull, not just the hamstrings) :
- 1st degree : a simple muscle pull, where you have damaged (read torn) less then 25% of the fibres of the muscle. The tendon is generally intact;
- 2nd degree : a more serious pull, or strain, where 25-70% of the fibres of the muscle bulk or the tendon have been damaged;
- 3rd degree : generally called a complete rupture, where the tendon completely (or almost completely) snaps.
So what makes you prone to rupture your hamstrings?
- The number one hamstring killer is the lack of flexibility. Like any muscle, the more you exercise a muscle, the bigger it gets. And the bigger the muscle gets, the shorter it becomes. Failure to stretch routinely makes your muscle an easy target for injury - a weak link - because it becomes constantly under tension. And we all know that anything that is constantly under tension will eventually collapse (or snap in this case!).
- Repetitive tendonitis: a tendonitis creates constant inflammation around the tendon, and a large build up of scar tissue, both known to weaken the tendon. Once the tendon is weak (from an unhealed or recurrent tendonitis) , any sustained tension on it can create some serious damage, like a strain.
- Muscle imbalance: your hamstrings should be at least 2/3 of the strength of your quadriceps (the muscles in the front of your thigh). For most people, it is only about ½, of even less. When you are running, your quadriceps ensure that your knee does not buckle upon heel strike (phase of the gait where you hit the ground with your heel). If they are too strong for the hamstrings, they will constantly drive your knee too far in extension, and create a repetitive pull on the hamstrings, creating some microscopic damage in the muscle, a weakness eventually leading to a tendonitis or a strain.
- Repetitive cortisone injections: for years doctors of medicine have been treating stubborn tendonitis with cortisone (or some other anti-inflammatory) injections. Some are more cautious than others and inject around the tendon, but some are bolder and inject directly in the tendon. Any injection creates a tiny hole in the tissue, and therefore the body creates some scar tissue to repair the hole. This eventually leads to serious weakness of the tendon. One or two injections in the tendon will not kill you, but DO NOT exceed three. And preferably, get your doctor to inject around the tendon instead, if the injection is really necessary.
- Poor posture: how can your posture affect your hamstrings you will ask? Well remember, hamstrings are attached on your pelvis. Your pelvis is the base of your spine, the base of the structure that supports all the muscles. Any poor posture affects or starts from the pelvis. So if you tend to stand like a gymnast, with your bum sticking out and a big curve in your low back, your are standing with what is called an anterior pelvic tilt. By doing so, you are pulling the ischial tuberosities up (where your hamstrings attach), elongating the hamstrings and creating a constant tension on them. They will not last very long until they manifest themselves! On the other hand, if you stand with the opposite type of posture, the posterior pelvic tilt (round shoulders, head poking forward), do not congratulate yourself, because you are not any better! You may not be pulling on the hamstrings, but you are pulling on the opposite muscles, the hip flexors. They then become hyper responsive due to the constant pull, and they tend to shut down the opposite muscles (a reflex mechanism), making your hamstrings (and gluteus too) very weak. Weak hamstrings? See above!
- Over training: for most orienteers, this should not be a problem!!! But for those of you out there that are training to increase running speed, be aware of those high intensity workouts. Too much too soon is very destructive. I mentioned earlier that hamstrings work particularly hard during sprints and hills, workouts of choice to increase speed and power. Too many of those with inappropriate warm up or rest in between repetitions and/or training sessions will make your hamstrings very fatigued and unable to recover, eventually making the muscle weak and prone to injury.
- Poor warm up: imagine your muscles like a piece of silly putty. When it is cool, it is very hard to stretch or mould or deform. The more you play with it, the warmer it gets and the easier it becomes to shape it. Well, your muscles are like that. If you start running fast or jumping over logs without any warm up, your muscles will not be able to elongate to meet the demand and will snap. As simple as that! (refer to ONA August 2001 for tips on warming up).
What to do, what to do…
You have been bad and managed to pull your hamstrings? Well, it will for sure keep you out of running for a while, but at least there is hope that you will heal completely.
First of all, make sure you have eliminated ALL of the above causes. If you are not flexible, refer to ONA May 2002 and start stretching! If you have weakness in your hamstrings, consult your personal trainer at the gym and look at ways to change that. If you suffer from repetitive tendonitis, well, there has got to be a cause for that somewhere. Find it and change it! You think that maybe your posture is inadequate, consult your physical therapist. Are you pushing too hard at training? You should never do 2 days in a row of high intensity workout, and during the workout, make sure you give yourself enough rest between the repetitions and that you are not doing too many repetitions; if you start feeling uncoordinated and slow, you are pushing too much. Cool down and go home. You don’t warm up properly – you know what I am going to say!
Hamstring Treatment 101
Once you have pinpointed the cause , and you are still suffering, here is what you can do.
Note: eliminating the cause is normally done after you have treated the injury. But since most people forget about it once the pain is gone, this method ensures you that you will get on it and not do it again!
1st and 2nd degree strains are treated the same way, but 2nd degree taking a little longer to heal than 1st. 3rd degree rupture is normally a surgery case, so we will not discuss the treatment, since you will be going to rehab anyway.
So for any other strain, you have to give the fibres a chance to heal, and this takes 3-4 weeks. This means rest. Imagine the ruptured muscle fibres like a cut on a finger: every time you bend your finger, you reopen the cut. It takes for ever to heal. Same for the muscle, every time you exercise it, you will reopen the wound. So take a break.
The first few days, you want to ice and ice and ice. It is fairly deep, so ice for at least 15 minutes, every 2 hours. At this point, the machines used in physiotherapy are very useful to help reduce the inflammation and promote the healing. Avoid walking if it is painful (crutches are always fun anyway!).
When you can finally walk without any pain, it is time to start working on the fibres. You have to be very gentle still, because they are still very fragile at this point. You can start to massage gently. This will help getting rid of the excessive scar tissue and also help the muscle to relax. As it gets better, you can start stretching, but is has to be painless. Stretch lots. Ice is still effective at this point, as long as you ice after the massage, and not before (silly putty, remember?).
You are now pain free and feel like you can start exercising. Begin with low weight and many repetitions (something like 3 x 15). Progress to more resistance, making sure that is it still pain free. When you feel like your muscle is strong again, you can try to go for an easy jog. Keep it short and easy. Increase the pace and the time progressively, making sure it still feels good. At this point, stretching becomes critical. Not only you want to recover full flexibility, but you want to increase it. You may still experience some discomfort (no pain though) due to spasm or scar tissue. It is now the last part of the treatment where you can start the deep tissue massage. Warm up the muscle (short jog, hot tub, hot pack), massage it deeply, stretch it, and then ice it. This should take care of the final phase of the rehab. Within 4 weeks (depending how bad the strain was of course), you should be back to where you were in your training. Enjoy running pain free again!