Final 0

FLEX THERAPIST CEUs
1422 Monterey Street, Suite C-102

San Luis Obispo, Ca 93401
Ph (805) 543-5100 Fax (805) 543-5106
www.flextherapistceus.com
Hamstring Strains – Prevention and Rehabilitation
Table of Contents
1. Diagnostic Accuracy of Clinical Tests for Assessment Pages 222-231

Of Hamstring Injury
2. Clinical and Morphological Changes Following 2 Pages 284- 299

Rehabilitation Programs for Acute Hamstring Strain
Injuries
3. Preventative Exercise Progression for Hamstring Strain Pages 1-15

[ research report ]
AMY SILDER, PhD1 • MARC A. SHERRY, PT, DPT, LAT, CSCS2 • JENNIFER SANFILIPPO, MS, LAT3
MICHAEL J. TUITE, MD4 • SCOTT J. HETZEL, MS5 • BRYAN C. HEIDERSCHEIT, PT, PhD6
Clinical and Morphological Changes

Following 2 Rehabilitation Programs
for Acute Hamstring Strain Injuries:
A Randomized Clinical Trial
A
cute hamstring strain injuries are common in 15%11,12,35,36 to more than
sports involving high-speed movements.7,11,14,24,32 50%.3,21 This has led to
speculation that inad-
Many athletes return to sport at a suboptimal
SUPPLEMENTAL equate rehabilitation
level of performance,32 which may contribute to VIDEO ONLINE
and/or a premature re-
high reinjury rates reported to vary from approximately turn to sport may be to
blame.21,24,31 Determining the type of re-
habilitation program that most effectively
TTSTUDY DESIGN: Randomized, double-blind, or morphological outcome measures between re-
habilitation groups across time, and reinjury rates
promotes muscle tissue and functional
parallel-group clinical trial.
recovery is essential to minimize the
TTOBJECTIVES: To assess differences between were low for both rehabilitation groups after return
to sport (4 of 29 subjects had reinjuries). Greater risk of reinjury and to optimize athlete
a progressive agility and trunk stabilization
rehabilitation program and a progressive running craniocaudal length of injury, as measured on MRI performance.
and eccentric strengthening rehabilitation program before the start of rehabilitation, was positively Neuromuscular control exercises9,23
in recovery characteristics following an acute ham- correlated with longer return-to-sport time. At and eccentric training1,2,7,13,25,28 have been
string injury, as measured via physical examination the time of return to sport, although all subjects
shown to reduce the likelihood of ham-
and magnetic resonance imaging (MRI). showed a near-complete resolution of pain and
return of muscle strength, no subject showed com- string injury and are advocated by many
TTBACKGROUND: Determining the type of reha- plete resolution of injury as assessed on MRI. to be included as part of rehabilitation
bilitation program that most effectively promotes
muscle and functional recovery is essential to TTCONCLUSION: The 2 rehabilitation programs following an acute strain injury. Eccentric
minimize reinjury risk and to optimize athlete employed in this study yielded similar results with strengthening, in particular, is believed to
performance. respect to hamstring muscle recovery and function increase the series compliance of muscle
TTMETHODS: Individuals who sustained a recent
at the time of return to sport. Evidence of continu- and allow for longer operating lengths,8,26
ing muscular healing is present after completion which may offset the effects of scar tis-
hamstring strain injury were randomly assigned
of rehabilitation, despite the appearance of normal
to 1 of 2 rehabilitation programs: (1) progressive sue.27 Alternatively, Sherry and Best30
physical strength and function on clinical examina-
agility and trunk stabilization or (2) progressive found significantly lower reinjury rates
tion.
running and eccentric strengthening. MRI and in athletes who completed a progressive
physical examinations were conducted before and TTLEVEL OF EVIDENCE: Therapy, level 1b–.
agility and trunk stabilization (PATS)
after completion of rehabilitation. J Orthop Sports Phys Ther 2013;43(5):284-299.
program, compared to those whose reha-
TTRESULTS: Thirty-one subjects were enrolled,
Epub 13 March 2013. doi:10.2519/jospt.2013.4452
TTKEY WORDS: MRI, muscle, return-to-sport
bilitation programs focused on isolated
29 began rehabilitation, and 25 completed
rehabilitation. There were few differences in clinical criteria hamstring strengthening and stretching.
The authors speculated that the inclu-
1
Department of Bioengineering and Department of Orthopaedic Surgery, Stanford University, Stanford, CA. 2Sports Rehabilitation, University of Wisconsin Health Sports Medicine,
Madison, WI. 3Athletics Department, University of Wisconsin-Madison, Madison, WI. 4Department of Radiology, University of Wisconsin-Madison, Madison, WI. 5Department of
Biostatistics and Medical Informatics, University of Wisconsin-Madison, Madison, WI. 6Department of Orthopedics and Rehabilitation and Department of Biomedical Engineering,
University of Wisconsin-Madison, Madison, WI. The authors certify that they have no affiliations with or financial involvement in any organization or entity with a direct financial
interest in the subject matter or materials discussed in the manuscript. This study was approved by the University of Wisconsin Health Sciences Institutional Review Boards.
Address correspondence to Dr Marc A. Sherry, University of Wisconsin Sports Medicine Center, 621 Science Drive, Madison, WI 53711. E-mail: MSherry@UWHealth.org t
Copyright ©2013 Journal of Orthopaedic & Sports Physical Therapy ®
284 | may 2013 | volume 43 | number 5 | journal of orthopaedic & sports physical therapy
43-05 Silder.indd 284 4/17/2013 3:49:33 PM

sion of exercises targeting muscles that ing (PRES) program. We hypothesized with sports/running. Subjects were ex-
control pelvic motion early in the reha- that athletes participating in the PATS cluded from this study if they were iden-
bilitation process might have facilitated program would display a greater amount tified as having a complete hamstring
recovery from injury and thereby mini- of muscle recovery at the time of return disruption or avulsion during the initial
mized reinjury risk. While both the PATS to sport compared to those in the PRES physical examination or MRI.
and the eccentric strengthening rehabili- group. We further hypothesized that, re-
tation programs are promising and may gardless of the rehabilitation employed, Randomization
be effective, they have not been directly the majority of athletes would display Following the initial physical exami-
compared with regard to restoring mus- continued signs of healing on MRI after nation, the treating physical therapist
cle integrity and function. being clinically cleared to return to sport. (M.A.S.) used a 4-block, fixed-allocation
It is possible that, regardless of the Further analyses of time needed to return randomization process to assign sub-
rehabilitation employed, clinical deter- to sport and MRI measurements were jects to 1 of the 2 rehabilitation groups
minants of recovery, as measured during performed to more fully characterize the (the PATS or PRES group). This ran-
physical exam (eg, no pain, full range of timeline of hamstring muscle recovery domization process allowed stratifica-
motion, and full strength), do not ad- following injury. tion for age, initial injury or recurrent
equately represent complete muscle reinjury, and mechanism of injury. These
covery and readiness to return to sport. METHODS variables have previously been shown to
Despite meeting clinical clearance, 37% affect return-to-sport time and reinjury
of the athletes in a study by Connell et Trial Design and Participants rates.3,7,15-17 The random allocation se-
T
al,10 as assessed with magnetic resonance his was an equal-randomized, quence was generated by an independent
imaging (MRI), showed continued evi- double-blind, parallel-group study. biostatistician.
dence of muscle healing after returning Potential subjects were identified
to sport, suggesting that athletes may be and recruited via physicians, athletic Interventions
in an injury-susceptible state.4,10,29,31,34 trainers, and physical therapists in Madi- Each subject completed rehabilita-
The use of MRI near the time of injury son, WI and the surrounding communi- tion with the same physical therapist
has an established prognostic role in es- ties over a 3-year period. To be eligible (M.A.S.), who was blinded to any infor-
timating convalescent period. A greater for enrollment, individuals had to pre mation obtained from the initial physical
amount of T2 hyperintensity, reflective of sent with a suspected hamstring injury examination and MRI. Each rehabilita-
edema, is associated with a longer reha- occurring within the prior 10 days, to be tion program had 3 treatment phases.
bilitation time. This correlation has been 16 to 50 years of age, and to be involved In the first phase, ice was applied to the
made using measurements of cranio- in sports that require high-speed running posterior thigh for 20 minutes after com-
caudal (CC) injury length,10,29,34 percent (eg, football) a minimum of 3 days per pleting each rehabilitation session. Sub-
cross-sectional area of injury,10,31 dis- week. All subjects or parents/guardians jects progressed into phase 2 when they
tance of maximum signal intensity from provided informed consent to participate could walk with the same stride length
the ischial tuberosity,4 and maximum T2 in this study, according to a protocol ap- and stance time on the injured and non-
hyperintensity.10,31 Regardless of the re- proved by the University of Wisconsin injured limbs (visually assessed) and
habilitation employed, determining the Health Sciences Institutional Review initiate a pain-free isometric hamstring
extent of remaining injury on MRI using Boards. All testing took place at the Uni- contraction at 90° of knee flexion with a
these same metrics following the com- versity of Wisconsin Hospital and Clinics. manual muscle testing grade judged to
pletion of a rehabilitation program may All enrolled subjects received a physi- be at least 4/5. Subjects progressed into
yield further insights into the readiness cal examination and MRI within 10 days phase 3 when they could jog forward and
of the athlete to return to sport. of the injury. Hamstring injury was con- backward with the same stride length and
The purpose of this study was to mon- firmed by physical examination conduct- stance time on the injured and nonin-
itor clinical and morphological changes ed by a physical therapist (B.C.H.) and jured limbs (visually assessed) and dem-
during the course of rehabilitation in was based on a sudden-onset mechanism onstrate 5/5 strength on manual muscle
individuals with acute hamstring strain and the presence of 2 or more of the fol- testing of the hamstrings in 3 conditions:
injuries and to determine if differences lowing: palpable pain along any of the prone at 90° of knee flexion with the tibia
in outcomes may exist between the 2 hamstring muscles, posterior thigh pain in neutral position, the tibia rotated in-
progressive rehabilitation programs. The without radicular symptoms during a ternally, and the tibia rotated externally.
rehabilitation programs utilized were a passive straight leg raise, weakness with The PATS group participated in a
modified PATS program30 and a progres- resisted knee flexion, pain with resisted modified version of the original PATS
sive running and eccentric strengthen- knee flexion, and/or posterior thigh pain rehabilitation program.30 The original
journal of orthopaedic & sports physical therapy | volume 43 | number 5 | may 2013 | 285
43-05 Silder.indd 285 4/17/2013 3:49:34 PM

[ research report ]
initial injury to completion of rehabilita-
tion. The CC length of injury, as measured
on MRI, was also of primary interest and
was measured as the total injured area,
accounting for the likelihood that more
than 1 muscle would show signs of inju-
ry.10,31,33 All MRI studies were conducted
using a phased-array torso coil in a 1.5-
T TwinSpeed scanner (GE Healthcare,
Waukesha, WI). T2-weighted axial and
coronal images were obtained using the
following scan parameters: TR/TEeff,
2200 to 3200 divided by 70 to 88 milli-
FIGURE 1. The percent cross-sectional area of injured muscle was estimated by considering all muscles that seconds; matrix, 512 × 512; 1 NEX; 5-mm
exhibited T2 hyperintensity. axial with no gap; and 4.0/0.4-mm coro-
nal. Images were interpreted by the same
PATS program was modified from 2 low-up visits were scheduled according musculoskeletal radiologist (M.J.T.), who
phases to 3 phases, which allowed for to patient progress and reported symp- was unaware of rehabilitation group al-
more progressive resistance during the toms, and participants were monitored location or clinical details other than sus-
trunk stabilization exercises and added a by phone calls or electronic mail every pected hamstring injury. Each image set
lunge walk that required trunk rotation few days. A minimum of 1 weekly clinic was examined separately to help ensure
and pelvic control with the hamstrings visit was required of all subjects to moni- unbiased measurements.
in a lengthened position (APPENDIX A). tor exercise technique and to re-evaluate Secondary Outcome Measures Medio-
The progressive agility exercises began their status. Subjects were allowed to re- lateral width and anterior/posterior
with movements primarily in the frontal turn to sport when they had no palpable depth of the total injured area were also
and transverse planes during phase 1 and tenderness along the posterior thigh, measured on MRI. The cross-sectional
progressed to agility and trunk stabiliza- demonstrated subjective readiness (no area (0.25 × π × mediolateral × anterior/
tion movements in the transverse and apprehension) after completing a series posterior) of the injury, as a percentage
sagittal planes during phase 2. Phase 3 of progressive sprints working up to full of the total cross-sectional area, was cal-
increased the speed and/or resistance of speed, and scored 5/5 on manual muscle culated at the level where the injury had
the exercises. testing of the hamstrings performed on the largest absolute cross-sectional distri-
The PRES group performed a rehabil- 4 consecutive repetitions in various knee bution in the muscle(s) (FIGURE 1).5,10,29,31,34
itation program consisting of progressive positions. Knee flexion isometric strength In addition, the axial slice on the initial
running and eccentric strengthening that testing was performed in prone with the examination with the brightest signal in-
was modeled after the work of Baquie hip in 0° of flexion and the knee flexed at tensity was used to measure maximum T2
and Reid6 (APPENDIX B). Phase 1 consisted 90° and 15°. Testing was performed with hyperintensity. On the final MRI, T2 hy-
of a short-stride jog and hamstring iso- the tibia in neutral, external rotation, and perintensity was measured at the corre-
metric exercises. Phase 2 incorporated internal rotation for both knee flexion sponding anatomical location. To account
concentric and eccentric strengthening angles. After being cleared to return to for variations in signal quality between
exercises, and phase 3 progressed to sport by the treating physical therapist, examinations, these values were normal-
intense eccentric strengthening with all subjects received a final physical exam ized to the average signal intensity in
a power component. Running during and MRI. Any subject who incurred a re- normal, uninjured muscle tissue at their
phases 2 and 3 consisted of performing injury at any time during rehabilitation respective time points. Finally, the site of
a series of sprints with progressive accel- or the 6 months following return to sport injury was categorized as having occurred
eration/deceleration (APPENDIX C). received a follow-up MRI as soon as pos- to the biceps femoris, semimembranosus,
Treatment implementation and re- sible after the reinjury and, at that point, or semitendinosus, as well as having oc-
turn-to-sport criteria were the same for discontinued study participation. curred in either the tendon or the proxi-
both rehabilitation groups. Rehabilita- mal, middle, or distal musculotendon
tion was to be completed 5 days per week Outcomes junction. Note that no subject in this
at home. Subjects were asked to track Primary Outcome Measures The prima- study experienced an injury to the distal
their compliance on an exercise log that ry outcome measure was return-to-sport aspect of any of the hamstring muscles.
was submitted at each follow-up visit. Fol- time (days), defined as the period from Both physical examinations were
43-05 Silder.indd 286 4/17/2013 3:49:36 PM

conducted by the same physical thera-
pist (B.C.H.), who was unaware of the Enrolled participants, n = 31
type of rehabilitation employed or any
information obtained from MRI. The
subjects’ use of ice and nonsteroidal an- Excluded, n = 2:
ti-inflammatory drugs (NSAIDs) prior • Complete avulsion, n = 1
• Lumbosacral pathology with
to enrollment was noted, and all sub-
referred thigh pain, n = 1
jects were asked to refrain from NSAIDs
once enrolled. The physical examination
included bilateral measures of range of
Randomized, n = 29
motion, strength, and both location and
distribution (length) of pain. Surface pal-
pation was used to determine the loca-
tion of maximal tenderness, which was
Allocated to the progressive Allocated to the progressive
measured (cm) relative to the ischial
agility and trunk stabilization running and eccentric
tuberosity. The total CC length (cm) of
(PATS) rehabilitation group, strengthening rehabilitation
pain in the muscle/tendon unit was also n = 16 group, n = 13
measured with palpation. The passive
straight leg raise was performed with
Hamstring reinjury, n = 1
the knee in full extension, whereas ac- Hamstring reinjury, n = 1
Dropped out of study, n = 2
tive and passive knee extension was per-
formed with the hip in 90° of flexion, and
joint angles were recorded at the instant Completed rehabilitation, n = 13 Completed rehabilitation, n = 12
of initial hamstring discomfort/pain on
the injured side. Isometric knee flexion Hamstring reinjury the same
strength was measured with the subject day as being cleared to
prone and the knee flexed to 90° and 15°. return to sport, but prior to
When the knee was flexed to 90°, knee return-to-sport testing, n = 1
flexion strength was also measured with
the lower leg in neutral, internal rota-
Completed return-to-sport testing, Completed return-to-sport testing,
tion, and external rotation. Isometric hip
n = 13 n = 11
extension strength was measured with
the knee at 0° and 90° of flexion. Pain
provocation was noted for all strength Anterior cruciate ligament tear,
tests, with strength recorded using a n=1
Hamstring reinjury, n = 1
standard manual muscle testing grading
scale. As part of the physical examina-
tion performed at the time of return to
Completed periodic follow-up Completed periodic follow-up
sport, subjects were asked (yes/no) if they phone or electronic phone or electronic
(1) were back to their preinjury level of correspondence through 12 correspondence through 12
performance, and, if not, whether the months after injury, n = 13 months after injury, n = 9
hamstring injury was a limiting factor,
(2) had any remaining symptoms, and (3)
FIGURE 2. Flow diagram outlining enrollment and testing procedures.
felt hamstring symptoms during running.
After returning to sport, reinjury oc-
currence was monitored by phone calls or muscle/tendon unit, and decreased abil- under the assumption that the standard
electronic mail at 2 weeks and at 3, 6, 9, ity to do sporting activities (perceived deviation of time to return to sport would
and 12 months. A subject was considered strength and power). be equal to the difference in time to re-
to have a reinjury if there was a specific turn to sport between the 2 rehabilitation
mechanism that caused a return of pos- Statistical Analysis programs. To achieve 80% power for a t
terior thigh pain, pain with resisted knee A priori sample-size calculation, based test under these assumptions, it was nec-
flexion, tenderness to palpation along the on time to return to sport, was performed essary to include 17 subjects per group.
43-05 Silder.indd 287 4/17/2013 3:49:37 PM

[ research report ]
All data were analyzed based on inten- 2 subjects sustained a reinjury during the Initial Physical Examination
tion to treat. Missing data were treated course of rehabilitation. One reinjury oc- The initial physical examination occurred
as missing at random. Subjects who sus- curred during the sprinting portion of a median (IQR) of 4 (3-6) days after in-
tained a reinjury were documented, and return-to-sport testing (subject 26, PRES jury in the PATS group and 6 (4-7) days
reinjury rates were compared between group). The other reinjury occurred dur- after injury in the PRES group (P = .161).
groups. The data of subjects who sus- ing phase 3 of the PATS program, while Subject questioning revealed that 17
tained a reinjury were included in the performing a single-leg chair bridge (sub- of the 29 subjects (9 of 16 in the PATS
analysis up to the time of reinjury and ject 27). A total of 25 subjects completed group and 8 of 13 in the PRES group)
considered as missing after the reinjury, rehabilitation; however, only 24 subjects took NSAIDs within 1 to 3 days after the
so as not to skew their rehabilitation (19 male, 5 female; mean  SD age, 24  injury and that 7 subjects (3 in the PATS
results. This method should not have 9 years; height, 1.80  0.09 m; weight, group) continued NSAID use until en-
greatly affected the results, because re- 79  15 kg) completed return-to-sport rollment in this study. All of the subjects
injury rates were uncommon and similar testing, because subject 3 sustained a re- reported using ice within 1 to 3 days af-
between the groups. injury on the same day he was cleared to ter injury, and 18 (8 in the PATS group)
Analysis of subject baseline character- return to sport but prior to his scheduled continued icing through enrollment in
istics between the 2 randomly assigned return-to-sport testing. this study. The median (IQR) distance of
rehabilitation groups was conducted us- maximum pain during palpation was 7.4
ing t tests or Wilcoxon rank-sum tests Initial MRI cm (0.0-16.1) distal to the ischial tuber-
for nonnormally distributed data and the The time of initial MRI relative to the osity in the PATS group and 7.1 cm (5.5-
Fisher exact test for categorical character- time of injury occurred later in the PRES 9.3) in the PRES group (P = .961). The
istics. Analysis of time to return to sport group, with a median (interquartile range mean  SD length of pain with palpation
was performed with a 2-sample t test. [IQR]) of 7 (6-7) days after injury, com- was 9.9  5.2 cm and 8.3  3.0 cm in
Analyses of change in variables over time pared to 5 (3-6) days in the PATS group the PATS and PRES groups, respectively
were examined with repeated-measures (P = .041). With respect to which muscles (P = .507). Manual strength testing re-
analyses of variance, with time, interven- were determined as being injured, the vealed that not all of the subjects exhibit-
tion group, and their interaction as fixed MRI and physical examinations agreed ed strength deficits on their injured limb
effects and subject as a random effect. in all but 9 of the 29 initial cases; 3 sub- during all tests; however, every subject
The repeated-measures analyses of vari- jects showed no abnormal T2 intensity on showed a strength deficit during at least
ance were used to estimate the mean and initial MRI, and 6 showed disagreement 1 strength test (TABLE 3). Range-of-motion
95% confidence interval (CI) at each of between the clinical and MRI diagnoses tests revealed that some of the subjects
the time points. Analyses of the associa- as to the primary muscle injured (TABLE 1). exhibited greater range of motion in their
tion of categorical outcomes and program The following results consider only injured limb compared to the uninjured
assignment were conducted with Fisher the 26 subjects with MRI indication of limb. No significant differences between
exact tests. The correlation between time injury (T2 hyperintensity). Injury was rehabilitation groups were found for
to return to sport and CC length of injury isolated to only 1 muscle in 12 subjects, any of the initial physical examination
per MRI measure was calculated with a visible in 2 muscles for 10 subjects, visible measurements.
Pearson correlation coefficient. All tests in 3 muscles for 3 subjects, and visible as
were 2 sided, and significance was set at T2 hyperintensity in 4 muscles for 1 sub- Primary Outcome Measures
α = .05. ject (group difference, P = .180) (TABLE 1). The mean  SD time to return to sport
The median (IQR) initial percent cross- was 28.8  11.4 days in the PRES reha-
RESULTS sectional area injured, when considering bilitation group and 25.2  6.3 days in
all muscles involved, was 63% (36%- the PATS rehabilitation group (P = .346).
O
f the 31 subjects enrolled, 1 79%) in the PATS group and 61% (48%- The mean CC length of injury from the
subject was excluded because of a 91%) in the PRES group (P = .233), and initial MRI examination was 12.8 cm
biceps femoris avulsion identified the mean  SD maximum T2 signal in- (95% CI: 7.7, 18.0) in the PATS group
on initial MRI, and 1 subject was ex- tensity was 3.1  1.0 times that of the un- and 17.3 cm (95% CI: 9.8, 24.7) in the
cluded due to sacroiliac pathology with injured muscle in the PATS group and 2.8 PRES group (P = .229). Initial CC length
referred posterior thigh pain (FIGURE 2).  0.7 times that of the uninjured muscle of injury was significantly associated with
Twenty-nine subjects began rehabilita- in the PRES group (P = .518) (TABLE 2). No a longer return-to-sport time (r = 0.41, P
tion. Two of those subjects dropped out significant differences between rehabili- = .040). At return to sport, CC length in
of the study without reinjury prior to tation groups were found for any of the the PRES group was 15.9 cm (95% CI:
completion of rehabilitation. In addition, initial MRI measurements. 8.4, 23.4) compared to 7.9 cm (95% CI:
43-05 Silder.indd 288 4/17/2013 3:49:38 PM

TABLE 1 Subject Characteristics*
Muscles Primary Distance From Return to Clinic Rehabilitation Compliance

Program/Subject Gender, Age Method of Injury Involved, n Muscle Primary Location Origin, cm Sport, d Visits, n (Completed/Assigned), d
PATS
4 Female, 16 y Sprinting 2 SM† Tendon 0.0 37 6 29/34
5 Male, 21 y Sprinting 1 BF Tendon 19.0 34 6 19/30
6 Male, 43 y Sprinting 1 BF† Mid-MTJ 12.4 33 4 20/27
11 Male, 18 y Sprinting 2 ST† Prox MTJ 0.0 28 5 12/13
12 Male, 25 y Sprinting 2 BF Prox MTJ 6.3 27 4 12/21
13 Female, 20 y Extreme stretch 0 NA† NA NA 23 4 13/17
14 Female, 18 y Cutting maneuver 1 SM Prox MTJ 21.2 23 5 16/20
16 Male, 40 y Sprinting 3 BF Mid-MTJ 12.6 23 4 18/20
18 Male, 20 y Sprinting 0 NA† NA NA 21 3 16/19
20 Male, 16 y Sprinting 2 ST Prox MTJ 8.5 20 3 12/12
23 Male, 21 y Extreme stretch 1 BF Distal MTJ 21.1 18 3 10/13
24 Female, 19 y Extreme stretch 0 NA† NA NA 17 3 12/13
27 Male, 36 y Sprinting 3 BF Mid-MTJ 5.2 Reinjury Reinjury NA
28 Male, 18 y Extreme stretch 2 BF Tendon 18.1 Dropout Dropout NA
29 Female, 30 y Sprinting 3 BF Tendon 0.0 Dropout Dropout NA
PRES
1 Male, 44 y Sprinting 2 BF† Prox MTJ 3.7 49 6 36/42
2 Male, 27 y Sprinting 4 BF Everywhere 4.4 47 7 35/40
3 Male, 17 y Sprinting 1 BF† Mid-MTJ 7.2 40 7 32/40
17 Male, 17 y Sprinting 1 BF† Prox MTJ 0.0 23 4 12/13
22 Male, 21 y Extreme stretch 1 SM Prox MTJ 5.5 19 2 11/13
25 Female, 22 y Cutting maneuver 1 SM Mid-MTJ 15.7 13 2 13/13
26 Male, 19 y Sprinting 2 BF Mid-MTJ 7.1 Reinjury Reinjury NA
Abbreviations: BF, biceps femoris; MRI, magnetic resonance imaging; MTJ, musculotendon junction; NA, not applicable; PATS, progressive agility and trunk
stabilization; PRES, progressive running and eccentric strengthening; Prox, proximal; SM, semimembranosus; ST, semitendinosus.
*Subjects are numbered and sorted based on return-to-sport time (number of days from injury until being cleared to return to sport). Sixteen subjects par-
ticipated in the PATS program and 13 subjects participated in the PRES program. MRI was used to determine the number of muscles involved in the injury,
the primary muscle injured, the primary location of injury, and the distance of injury from the ischial tuberosity (distance of maximum T2 hyperintensity).
Compliance of home rehabilitation was calculated as the ratio of completed home rehabilitation days (per self-report exercise log) divided by the number of
days assigned. NA represents no MRI indication of injury (ie, no T2 hyperintensity). No subject in this study experienced an injury to the distal aspect of the
muscle; therefore, all injury locations are relative to the proximal aspect of the muscle.
†
With respect to the muscle injured, the physical examination diagnosis and MRI disagreed in 9 subjects. No T2 hyperintensity was present in the initial MRI
examination of 3 subjects. The muscles injured, as determined from the initial physical examination, in these subjects were as follows: subject 13, ST and SM;
subject 18, common insertion; subject 24, ST and SM. The muscles injured, as determined on the initial physical examination, for the remaining 6 subjects
were as follows: subject 1, ST and SM; subject 3, ST; subject 4, BF; subject 6, SM; subject 11, BF; subject 17, ST.
2.7, 13.1) in the PRES group (P = .037). pared to 5.0 cm (95% CI: 2.7, 7.2) for a result, the change in CC injury length
The subjects in the PRES group also dis- those in the PATS group (P = .035). Ede- over the course of rehabilitation was vari-
played less improvement in injury length, ma and hemorrhage can extend into the able among all subjects, ranging from a
with an average improvement from base- fascial plane, which can lengthen the CC 137% increase in length (subject 22) to
line of 1.4 cm (95% CI: –1.9, 4.7) com- extent of injury over time (FIGURE 3). As a 100% decrease in length. The mean 
43-05 Silder.indd 289 4/17/2013 3:49:39 PM

[ research report ]

Summary of MRI Measures Conducted Before
TABLE 2
and After Completion of Rehabilitation*
Craniocaudal Length, cm Cross-sectional Area, % Normalized Maximum T2 Hyperintensity

Program/Subject Initial Final Initial Final Initial Final
PATS
4 3.2 0.0 100 0 1.5 1.2
5 9.3 7.3 25 37 1.9 1.6
6 18.8 5.5 79 1 2.5 1.7
11 23.7 22.8 71 55 4.6 3.4
12 17.1 6.9 20 2 3.3 2.0
13 NA NA NA NA NA NA
14 7.7 2.5 47 6 3.4 2.0
15 16.6 6.8 36 14 3.5 2.2
16 25.2 23.5 79 55 3.5 2.9
20 12.8 3.6 33 12 4.2 1.4
23 12.2 4.8 40 43 2.6 2.5
27 33.1 Reinjury 100 Reinjury 1.5 Reinjury
28 19.3 Dropout 86 Dropout 3.3 Dropout
29 13.6 Dropout 100 Dropout 4.1 Dropout
PRES
1 15.6 11.4 64 22 2.4 2.1
2 35.5 28.6 48 28 2.9 3.3
7 30.4 27.8 55 16 2.1 2.1
8 23.5 23.1 61 33 1.8 1.5
9 15.5 12.5 100 40 3.0 2.6
10 8.7 8.6 35 13 3.4 2.5
17 24.1 22.8 91 100 2.8 2.4
19 7.9 10.4 16 30 3.0 2.8
21 13.1 14.6 100 25 2.4 1.6
22 5.2 12.3 70 43 4.6 2.2
25 8.7 2.3 9 2 2.1 1.9
Abbreviations: MRI, magnetic resonance imaging; NA, not applicable; PATS, progressive agility and trunk stabilization; PRES, progressive running and
eccentric strengthening.
*MRI was used to determine the craniocaudal length of injury, percent cross-sectional area, and normalized maximum T2 hyperintensity after injury and
after completion of rehabilitation. Because more than 1 muscle is often injured,10,31,33 craniocaudal length and percent cross-sectional area were measured with
respect to the total injured area. NA represents no magnetic resonance imaging indication of injury (no T2 hyperintensity).
SD improvement of only those subjects median (IQR) number of clinic visits was 12%, P = .070). No significant differences
with MRI indication of injury who com- 4 (3-5) in both groups, and subjects com- in return-to-sport time, clinic visits, or
pleted all rehabilitation and testing (24 pleted a median (IQR) of 20 (13-21) days rehabilitation compliance were noted
subjects) was 39%  35% (TABLE 2). of rehabilitation at home in the PATS between rehabilitation groups.
group and 21 (13-28) days in the PRES Final MRI No subject showed complete
Secondary Outcome Measures group (P = .577). Based on self-reported injury resolution (no T2 hyperintensity)
Rehabilitation The median (IQR) num- exercise logs, rehabilitation compliance after being cleared to return to sport
ber of days until return to sport was 23 was slightly but not significantly higher (TABLE 2). The mean percent cross-sec-
(21-28) and 28 (20-33) in the PATS and in the PRES group (mean  SD, 88% tional area injured, when considering all
PRES groups, respectively (P = .512). The  9%) than in the PATS group (80%  muscles involved, was 45.0% (95% CI:
43-05 Silder.indd 290 4/17/2013 3:49:40 PM

Summary of Physical Examination Results Conducted
TABLE 3
Before and After Completion of Rehabilitation*
PATS† PRES‡
Noninjured Injured Reported Pain, n Noninjured Injured Reported Pain, n
Initial evaluation
Hip extension strength§
Knee flexed 5 (4– to 5) 4 (2 to 5) 7 5 (4+ to 5) 4+ (3 to 5) 5
Knee extended 5 (4+ to 5) 4 (2 to 5) 9 5 (4+ to 5) 4 (3 to 5) 8
Knee flexion strength§
Knee flexed to 15° 5 (5) 4– (3 to 4+) 10 5 (5) 4– (3+ to 5) 11
Knee flexed to 90° 5 (5) 4 (3+ to 4+) 10 5 (5) 4 (4– to 5) 10
Knee flexed to 90° with IR 5 (5) 4 (3 to 5) 8 5 (5) 4 (3 to 5) 7
Knee flexed to 90° with ER 5 (5) 4 (4– to 5) 5 5 (5) 4 (3+ to 5) 7
Straight leg raise, deg║ 81  14 63  18 … 80  15 70  16 …
Active knee extension, deg║ 23  10 21  21 … 29  12 26  9 …
Passive knee extension, deg║ 34  17 34  20 … 39  22 35  21 …
Length of pain with palpation, cm║ 0.0 9.9  5.2 … 0.0 8.3  3.0 …
Final evaluation
Hip extension strength§
Knee flexed 5 (4+ to 5) 5 (4+ to 5) 0 5 (5) 5 (4+ to 5) 1
Knee extended 5 (4+ to 5) 5 (4+ to 5) 0 5 (5) 5 (4+ to 5) 0
Knee flexion strength§
Knee flexed to 15° 5 (5) 5 (4 to 5) 1 5 (5) 5 (5) 0
Knee flexed to 90° 5 (5) 5 (4+ to 5) 0 5 (5) 5 (4+ to 5) 1
Knee flexed to 90° with IR 5 (5) 5 (4 to 5) 1 5 (5) 5 (4+ to 5) 1
Knee flexed to 90° with ER 5 (5) 5 (5) 0 5 (5) 5 (5) 0
Straight leg raise, deg║ 86  14 83  13 … 78  13 80  13 …
Active knee extension, deg║ 18  8 18  10 … 26  12 23  11 …
Passive knee extension, deg║ 13  9 13  9 … 21  11 18  9 …
Length of pain with palpation, cm║ 0.0 0.0 … 0.0 0.0 …
Abbreviations: ER, external rotation; IR, internal rotation; PATS, progressive agility and trunk stabilization; PRES, progressive running and eccentric
strengthening.
*Two of the original 29 subjects dropped out of the study and 2 subjects sustained a reinjury prior to completion of rehabilitation.
†
At initial evaluation, n = 16; at final evaluation, n = 13.
‡
At initial evaluation, n = 13; at final evaluation, n = 11.
§
Values are median (range of scores reported), with a 5-point maximum. Isometric strength tests were done using a standard manual muscle testing grading
scale. For each strength test, the number of subjects who reported pain in their injured limb is indicated.
║
Values are mean  SD.
28.9%, 61.1%) at baseline in the PATS CI: 9.8%, 47.4%) in the PRES group (P PATS group and 4 of 12 remaining sub-
group and 61.9% (95% CI: 38.8%, 85.1%) = .822). The mean normalized T2 signal jects in the PRES group) indicated that
at baseline in the PRES group (P = .145). intensity decreased from baseline slightly they felt remaining hamstring symptoms
The PATS group improved to a remaining more in the PATS group (–0.75; 95% CI: (eg, pain, tightness) after being cleared
mean percent cross-sectional injured area –1.2, –0.31) compared to the PRES group to return to sport (P = .444). Twelve
of 19.2% (95% CI: 2.6%, 35.8%) at follow- (–0.50; 95% CI: –0.98, –0.03), but this subjects (7 in the PATS group and 5 in
up, compared to 33.3% (95% CI: 9.0%, difference was not significant (P = .438). the PRES group) indicated that they did
57.7%) in the PRES group (P = .244). Finally, the presence of early scar tissue not feel that they had returned to their
The mean improvement from baseline formation was apparent in many of the preinjury level of performance (P = 1.0).
in percent cross-sectional area injured subjects (FIGURES 3 and 4). However, only 3 subjects (2 in the PATS
was 25.8% (95% CI: 8.3%, 43.3%) in the Final Physical Examination Eleven sub- group and 1 in the PRES group) reported
PATS group, compared to 28.6% (95% jects (7 of 13 remaining subjects in the that their hamstring injury was a limit-
43-05 Silder.indd 291 4/17/2013 3:49:41 PM

[ research report ]
turn to sport, only 5 subjects (1 in the
PATS group and 4 in the PRES group)
reported continued symptoms that lim-
ited their normal participation in sport.
At approximately 6 weeks after return to
sport, subject 10 (PRES group) ruptured
the anterior cruciate ligament in the con-
tralateral knee while landing from a jump
while playing basketball, thereby limiting
participation in sport. At 3, 6, 9, and 12
months following return to sport, any-
where between 2 and 5 subjects reported
continuing symptoms.
MRI of Reinjury
Of the 4 subjects who sustained a rein-
jury, only 3 received additional MRI. Re-
injuries for those 3 subjects occurred in
generally the same location as the initial
injury, and injury severity did not ap-
pear worse than the initial injury (FIGURE
4). To help establish whether any MRI
FIGURE 3. Coronal and axial T2-weighted MRI scans taken after injury (A and B) and after completion of measurement could be a predictor of re-
rehabilitation (C and D). The tendon of the injured limb can initially appear wavy (A; arrow). Scar tissue begins injury, post hoc analysis was conducted
to form during the course of rehabilitation and is clearly visible on MRI scans obtained after completion of to compare the extent of muscle dam-
rehabilitation (C and D; arrows). Edema and hemorrhage (T2 hyperintensity) can extend into the fascial plane (A age measured on initial MRI between
and B). Over the course of time, fascial drainage can lengthen the craniocaudal extent of injury and result in MRI
the 4 subjects who were reinjured and
measurements longer than the actual muscle/tendon damage. T2 hyperintensity was often more concentrated
during the initial MRI examination (A and B), compared to a more diffuse signal present in the follow-up MRI the other 25 subjects. The reinjured sub-
examination (C and D). Abbreviation: MRI, magnetic resonance imaging. jects had a significantly greater percent
area injured on initial MRI (4 reinjured
ing factor in their performance, and gen- consistent with the findings at baseline, subjects, 87% [95% CI: 68%, 100%];
eral deconditioning was the most cited where the side-to-side difference was the remaining 25 subjects, 54% [95%
limiting factor. Pain with palpation and 18.6° (95% CI: 11.6°, 25.7°) for the PATS CI: 43%, 65%]; P = .015). CC length and
during manual strength tests was nearly group and 9.4° (95% CI: 2.0°, 16.7°) for normalized T2 hyperintensity were not
absent for all subjects at the time of re- the PRES group (P = .074). No signifi- significantly different between the 4 sub-
turn to sport (TABLE 3). The subjects in cant differences between rehabilitation jects who reinjured themselves and the
the PRES group showed greater range groups were observed during the final remainder of subjects.
of motion during the straight leg raise in physical examination or in the amount
the noninjured limb at the final physical of improvement between the initial and DISCUSSION
exam, as opposed to those in the PATS final physical examinations.
T
group, who exhibited greater range of he purpose of this study was to
motion in the injured limb. Additionally, Symptoms and Reinjury compare clinical and morphologi-
the subjects in the PRES group tended Through 12 Months cal recovery characteristics between
to show greater mean side-to-side differ- Two of the 4 subjects who reinjured 2 progressive rehabilitation programs for
ence in the straight leg raise (noninjured themselves did so between comple- an acute hamstring strain injury. Despite
limb – injured limb) at the final physical tion of rehabilitation and the follow- all subjects achieving a nearly complete
examination (3.4°; 95% CI: –4.0°, 10.7°) ing 12-month period. Subject 3 (PRES resolution of pain and return of isometric
compared to those in the PATS group group) sustained a reinjury on the same muscle strength on physical examination
(–1.8°; 95% CI: –9.7°, 6.2°), but that dif- day as being cleared to return to sport, following completion of rehabilitation
ference was not significant (P = .337). and subject 17 (PRES group) sustained (TABLE 3), no subjects exhibited complete
This trend in the magnitude of the side- a reinjury 4 days after completion of resolution of injury on MRI (TABLE 2),
to-side difference between groups was rehabilitation. At 2 weeks following re- and early signs of scar tissue formation
43-05 Silder.indd 292 4/17/2013 3:49:42 PM

were apparent for most subjects (FIGURES
3 and 4). Contrary to our first hypothesis,
there were few differences between reha-
bilitation groups with respect to muscle
recovery and function. Most notably, re-
turn-to-sport times were similar between
groups, and overall reinjury rates were
low (1 of 16 subjects in the PATS group
and 3 of 13 subjects in the PRES group).
In support of our hypothesis, the
presence of injury on MRI was not re-
solved when subjects returned to sport.
Throughout the course of rehabilitation,
the size of injury increased for some
subjects in terms of both CC length and
cross-sectional area (TABLE 2). Cross-
sectional area increased as a result of a
more diffuse but larger distribution of
T2 hyperintensity. At the time of return
to sport, the CC length of injury was
longer for the PRES group compared to
the PATS group. Nevertheless, few clini-
cal conclusions can be drawn from this FIGURE 4. Coronal and axial T2-weighted magnetic resonance images of subject 3, taken after initial injury (A and
B) and 7 days after reinjury (C and D). The location of reinjury was similar to the initial injury. Early signs of scar
result, because edema drainage into the
tissue formation can be seen on the second set of images (C and D; arrows).
fascial plane may occur during the course
of rehabilitation and increase the appar-
ent CC length of injury and extend the grams, which is likely a key factor as to hemorrhage are often present in more
MRI measurements beyond the actual why so few subjects sustained reinjuries. than 1 muscle,10,31,33 we chose to estimate
muscle/tendon damage (FIGURE 3). Al- Although we observed very few differenc- percent cross-sectional area relative to all
though cross-sectional area and volume es in recovery features between rehabili- of the muscles involved in the initial in-
of injury are relevant indicators of dam- tation groups, one potential limitation of jury. We believe that this serves as a more
aged tissue,10,31 our findings suggest that the PRES rehabilitation program is that comprehensive assessment of initial in-
changes in these measures over time may the majority of the rehabilitation exer- jury severity.
not be good indicators of injury recovery. cises were only performed on the injured It is interesting to note that the 2 sub-
Through 1 year after return to sport, limb. This was done to ensure the stimu- jects (subjects 2 and 11) who exhibited
only 4 of the 29 subjects had sustained lus was applied to the injured leg and not some of the greatest remaining muscle
a reinjury, which is a substantially lower compensated for by the uninjured leg. injury on final MRI were also the 2 sub-
rate than that reported by most of the We did not observe any clinical strength jects with the greatest reported pain and
previous studies.3,11,12,21,35,36 Of these 4 re- deficits at return to sport (TABLE 3) or ap- strength deficits during the final physi-
injuries, 2 occurred during rehabilitation prehension with sports-specific explosive cal examination. Specifically, the CC
and 2 within the first 2 weeks after return movements, but it is possible that neuro- lengths of injury for subject 2 (28.6 cm)
to sport. The median return-to-sport time muscular imbalances exist upon return and subject 11 (22.8 cm) were both sub-
was 23 days, approximately 1 week longer to sport. stantially longer than the group average
than other reported times.7,18 Seriousness The CC length of injury as measured (15.3 cm) of those that did not reinjure
of participation in sport may affect the by MRI at the time of injury has been from both groups. (TABLE 2). This finding
commitment of an athlete to complete advocated as a strong predictor of time supports the idea that edema and hem-
rehabilitation without undue desire to needed to return to sport.4,10,29,31 Our re- orrhage are related to discomfort and
return to sport too quickly. Specifically, sults support these findings. However, loss of strength.19,20 Regardless, 3 sub-
unlike other investigations,3,11,12,35,36 none when considering the size of initial injury, jects presented with clinical indication
of the subjects in this study were profes- past studies have considered only the pri- of hamstring strain injury but showed no
sional athletes. Further, we utilized 2 of mary muscle involved when making MRI signs of T2 hyperintensity on their initial
the most supported rehabilitation pro- measurements.4,10,29,31 Because edema and or final MRI examinations (TABLE 2). This
43-05 Silder.indd 293 4/17/2013 3:49:44 PM

[ research report ]
is not uncommon, as it has been found recreational athletes to obtain MRI fol- produced similar results with respect to
that 18 of 58 athletes enrolled in a previ- lowing injury. Consistent with common muscle recovery and function following
ous study29 showed clinical indication of clinical practice, we measured strength a hamstring strain injury. Athletes par-
hamstring injury but no sign of injury on using isometric manual muscle testing ticipating in both rehabilitation groups
MRI; 17 of these 18 athletes were classi- procedures. Though this measure may continued to show indication of injury
fied as having a grade 1 injury. It is there- be less sensitive than computerized as- on MRI following completion of reha-
fore possible that MRI evidence of injury sessments involving a dynamometer, bilitation, despite meeting clinical clear-
may not be present for mild, yet painful, we opted to assess isometric strength at ance to return to sport.
hamstring injuries. multiple joint positions, including short IMPLICATIONS: The physical therapist
Compared to the initial injury, reinju- and long lengths of the hamstring mus- should consider that hamstring muscle
ries within the same playing season have cles. Finally, we were unable to enroll 17 recovery continues after an athlete
been shown to occur at the same location subjects in each rehabilitation group, as meets clinical clearance to return to
and to be more severe on MRI.22 Based we initially estimated. However, our rela- sport.
on the follow-up MRI measures in sub- tively small subject numbers and diverse CAUTION: The relatively small sample
jects who had sustained a reinjury in this athletic population allowed us to present size in this study limits any conclusions
study, the reinjuries occurred in the same valuable data for clinicians on individual regarding the effectiveness of either
location as the initial injury but were not athletes, which highlights how diversity rehabilitation program at minimizing
substantially worse (FIGURE 4). It is un- among athletes and injury characteristics reinjury risk.
clear what might have caused the con- may affect recovery during the course of
trast between these findings across the 2 rehabilitation. ACKNOWLEDGEMENTS: This study was fund-
studies. Post hoc analysis indicated that ed by the National Football League Medical
the percent area injured on initial MRI CONCLUSION Charities, the National Institutes of Health
in the 4 subjects who sustained reinjuries (RR 025011), and the University of Wiscon-
I
was significantly greater than that in the n general, subjects with an acute sin Sports Medicine Classic Fund. We thank
subjects who were not reinjured. Percent hamstring strain injury treated with ei- Michael O’Brien and Karolyn Davidson for
injured area, when including all muscles ther the PATS or PRES rehabilitation their help with data analysis.
injured, may be a clinically relevant mea- program demonstrated a similar degree
sure to aid in determining which subjects of muscle recovery at the time of return
are most at risk for reinjury; however, to sport. Despite this, there were no sub-
further study is needed to investigate the jects who exhibited complete resolution REFERENCES
relationship between reinjury rates and of injury on MRI, and 2 of the 4 subjects
1. A rnason A, Andersen TE, Holme I, Engebretsen
percent injured cross-sectional area. who reinjured themselves did so within L, Bahr R. Prevention of hamstring strains in
There are several limitations in the the first 2 weeks after return to sport. It elite soccer: an intervention study. Scand J
present study that prevented direct com- remains to be known how the gradually Med Sci Sports. 2008;18:40-48. http://dx.doi.
parisons with the literature and statisti- decreasing presence of injury on MRI af- org/10.1111/j.1600-0838.2006.00634.x
2. Askling C, Karlsson J, Thorstensson A.
cal conclusions and correlations between fects risk of reinjury once athletic activ- Hamstring injury occurrence in elite soccer
the imaging and clinical measurements ity is resumed. Given the results of this players after preseason strength training with
performed in this study. As some stud- study, it is important that clinicians rec- eccentric overload. Scand J Med Sci Sports.
ies have done,30 we used the period from ognize the presence of ongoing hamstring 2003;13:244-250.
3. Askling C, Saartok T, Thorstensson A. Type
injury to completion of rehabilitation as muscle healing upon completion of a su- of acute hamstring strain affects flexibility,
our definition of return-to-sport time, pervised rehabilitation program, despite strength, and time to return to pre-injury level.
whereas others have used return to com- the appearance of normal strength and Br J Sports Med. 2006;40:40-44. http://dx.doi.
petition10,29 or return to preinjury level function on clinical examination. Based org/10.1136/bjsm.2005.018879
4. Askling CM, Tengvar M, Saartok T, Thorstensson
of performance.4,5 Thus, our return-to- on these findings, athletes may benefit
A. Acute first-time hamstring strains during
sport time interval (median, 23 days) from a gradual return to the demands of high-speed running: a longitudinal study includ-
was considerably less than that of others full sporting activity and from continued ing clinical and magnetic resonance imaging
(median, 112 days).4 A consistent limita- independent rehabilitation after return to findings. Am J Sports Med. 2007;35:197-206.
sport to aid in minimizing reinjury risk. t
http://dx.doi.org/10.1177/0363546506294679
tion between our study and others10,29,34
5. Askling CM, Tengvar M, Saartok T, Thorstensson
is the use of MRI at the time of injury. A. Acute first-time hamstring strains during
Although MRI measurements may aid KEY POINTS slow-speed stretching: clinical, magnetic reso-
the diagnosis and treatment of hamstring FINDINGS: A modified PATS rehabilita- nance imaging, and recovery characteristics.
Am J Sports Med. 2007;35:1716-1724. http://
strain injuries, it is not feasible for most tion program and a PRES program
43-05 Silder.indd 294 4/17/2013 3:49:45 PM

dx.doi.org/10.1177/0363546507303563 org/10.1111/j.1600-0838.2005.00441.x ing can prevent hamstring injuries in soccer
6. B aquie P, Reid G. Management of hamstring 17. G
abbe BJ, Finch CF, Bennell KL, Wajswelner H. players. J Physiother. 2012;58:58. http://dx.doi.
pain. Aust Fam Physician. 1999;28:1269-1270. Risk factors for hamstring injuries in commu- org/10.1016/S1836-9553(12)70074-7
7. Brooks JH, Fuller CW, Kemp SP, Reddin DB. nity level Australian football. Br J Sports Med. 29. Schneider-Kolsky ME, Hoving JL, Warren P,
Incidence, risk, and prevention of hamstring 2005;39:106-110. http://dx.doi.org/10.1136/ Connell DA. A comparison between clinical
muscle injuries in professional rugby union. Am bjsm.2003.011197 assessment and magnetic resonance imag-
J Sports Med. 2006;34:1297-1306. http://dx.doi. 18. Gibbs NJ, Cross TM, Cameron M, Houang MT. ing of acute hamstring injuries. Am J Sports
org/10.1177/0363546505286022 The accuracy of MRI in predicting recovery Med. 2006;34:1008-1015. http://dx.doi.
8. Butterfield TA. Eccentric exercise in vivo: and recurrence of acute grade one hamstring org/10.1177/0363546505283835
strain-induced muscle damage and adapta- muscle strains within the same season in Aus- 30. Sherry MA, Best TM. A comparison of 2 reha-
tion in a stable system. Exerc Sport Sci Rev. tralian Rules football players. J Sci Med Sport.
bilitation programs in the treatment of acute
2010;38:51-60. http://dx.doi.org/10.1097/ 2004;7:248-258.
hamstring strains. J Orthop Sports Phys Ther.
JES.0b013e3181d496eb 19. Holm B, Kristensen MT, Bencke J, Husted H,
2004;34:116-125. http://dx.doi.org/10.2519/
9. Cameron ML, Adams RD, Maher CG, Misson Kehlet H, Bandholm T. Loss of knee-extension
jospt.2004.1062
D. Effect of the HamSprint Drills training pro- strength is related to knee swelling after total
31. Slavotinek JP, Verrall GM, Fon GT. Hamstring
gramme on lower limb neuromuscular control knee arthroplasty. Arch Phys Med Rehabil.
injury in athletes: using MR imaging measure-
in Australian football players. J Sci Med Sport. 2010;91:1770-1776. http://dx.doi.org/10.1016/j.
2009;12:24-30. http://dx.doi.org/10.1016/j. apmr.2010.07.229 ments to compare extent of muscle injury with
jsams.2007.09.003 20. Howell JN, Chleboun G, Conatser R. Muscle amount of time lost from competition. AJR Am
10. Connell DA, Schneider-Kolsky ME, Hoving JL, et stiffness, strength loss, swelling and soreness J Roentgenol. 2002;179:1621-1628. http://dx.doi.
al. Longitudinal study comparing sonographic following exercise-induced injury in humans. J org/10.2214/ajr.179.6.1791621
and MRI assessments of acute and healing Physiol. 1993;464:183-196. 32. Verrall GM, Kalairajah Y, Slavotinek JP, Spriggins
hamstring injuries. AJR Am J Roentgenol. 21. Jonhagen S, Nemeth G, Eriksson E. Hamstring AJ. Assessment of player performance following
2004;183:975-984. http://dx.doi.org/10.2214/ injuries in sprinters. The role of concentric and return to sport after hamstring muscle strain
ajr.183.4.1830975 eccentric hamstring muscle strength and flex- injury. J Sci Med Sport. 2006;9:87-90. http://
11. Ekstrand J, Healy JC, Walden M, Lee JC, English ibility. Am J Sports Med. 1994;22:262-266. dx.doi.org/10.1016/j.jsams.2006.03.007
B, Hagglund M. Hamstring muscle injuries in 22. Koulouris G, Connell DA, Brukner P, Schneider- 33. Verrall GM, Slavotinek JP, Barnes PG, Fon GT.
professional football: the correlation of MRI Kolsky M. Magnetic resonance imaging Diagnostic and prognostic value of clinical
findings with return to play. Br J Sports Med. parameters for assessing risk of recurrent findings in 83 athletes with posterior thigh
2012;46:112-117. http://dx.doi.org/10.1136/ hamstring injuries in elite athletes. Am J injury: comparison of clinical findings with
bjsports-2011-090155 Sports Med. 2007;35:1500-1506. http://dx.doi. magnetic resonance imaging documentation
12. Elliott MC, Zarins B, Powell JW, Kenyon org/10.1177/0363546507301258 of hamstring muscle strain. Am J Sports Med.
CD. Hamstring muscle strains in profes- 23. Kraemer R, Knobloch K. A soccer-specific bal- 2003;31:969-973.
sional football players: a 10-year review. Am J ance training program for hamstring muscle 34. Verrall GM, Slavotinek JP, Barnes PG, Fon GT,
Sports Med. 2011;39:843-850. http://dx.doi. and patellar and Achilles tendon injuries: an Esterman A. Assessment of physical examina-
org/10.1177/0363546510394647 intervention study in premier league female tion and magnetic resonance imaging findings
13. Engebretsen AH, Myklebust G, Holme I, Enge- soccer. Am J Sports Med. 2009;37:1384-1393.
of hamstring injury as predictors for recurrent
bretsen L, Bahr R. Prevention of injuries among http://dx.doi.org/10.1177/0363546509333012
injury. J Orthop Sports Phys Ther. 2006;36:215-
male soccer players: a prospective, random- 24. Orchard J, Best TM. The management of muscle
224. http://dx.doi.org/10.2519/jospt.2006.2086
ized intervention study targeting players with strain injuries: an early return versus the risk of
35. Warren P, Gabbe BJ, Schneider-Kolsky M, Ben-
previous injuries or reduced function. Am J recurrence. Clin J Sport Med. 2002;12:3-5.
nell KL. Clinical predictors of time to return
Sports Med. 2008;36:1052-1060. http://dx.doi. 25. Petersen J, Thorborg K, Nielsen MB, Budtz-
to competition and of recurrence following
org/10.1177/0363546508314432 Jørgensen E, Hölmich P. Preventive effect of
14. Feeley BT, Kennelly S, Barnes RP, et al. Epi- eccentric training on acute hamstring injuries in hamstring strain in elite Australian footballers.
demiology of National Football League train- men’s soccer: a cluster-randomized controlled Br J Sports Med. 2010;44:415-419. http://dx.doi.
ing camp injuries from 1998 to 2007. Am J trial. Am J Sports Med. 2011;39:2296-2303. org/10.1136/bjsm.2008.048181
Sports Med. 2008;36:1597-1603. http://dx.doi. http://dx.doi.org/10.1177/0363546511419277 36. Woods C, Hawkins RD, Maltby S, Hulse M,
org/10.1177/0363546508316021 26. Philippou A, Maridaki M, Bogdanis G, Halapas Thomas A, Hodson A. The Football Association
15. Gabbe BJ, Bennell KL, Finch CF. Why are A, Koutsilieris M. Changes in the mechanical Medical Research Programme: an audit of inju-
older Australian football players at greater properties of human quadriceps muscle after ries in professional football—analysis of ham-
risk of hamstring injury? J Sci Med Sport. eccentric exercise. In Vivo. 2009;23:859-865. string injuries. Br J Sports Med. 2004;38:36-41.
2006;9:327-333. http://dx.doi.org/10.1016/j. 27. Proske U, Morgan DL, Brockett CL, Percival P. http://dx.doi.org/10.1136/bjsm.2002.002352
jsams.2006.01.004 Identifying athletes at risk of hamstring strains
16. Gabbe BJ, Bennell KL, Finch CF, Wajswelner and how to protect them. Clin Exp Pharma-
@ MORE INFORMATION
H, Orchard JW. Predictors of hamstring injury col Physiol. 2004;31:546-550. http://dx.doi.
at the elite level of Australian football. Scand org/10.1111/j.1440-1681.2004.04028.x
J Med Sci Sports. 2006;16:7-13. http://dx.doi. 28. Schache A. Eccentric hamstring muscle train- WWW.JOSPT.ORG
43-05 Silder.indd 295 4/17/2013 3:49:45 PM

[ research report ]
APPENDIX A
The progressive agility and trunk stabilization program consisted of 3 phases. The program was designed to last approximately 2 to 6 weeks but
progressed on a subject-specific basis, using criteria as indicated. Intensity was used to guide the stationary biking and agility exercises. Descriptions of
the intensity levels were given to athletes and assessed qualitatively during the activity. Low intensity was described as little to no exertion; this intensity
can be thought of as primarily used to create motion. Moderate intensity was described as that above daily activity, with some perceived exertion. High
intensity was described as a perceived exertion near that of competitive sports.
Exercises Sets
Phase 1 Stationary bike 1 × 10 min
• Low intensity
10-m back-and-forth sidestep shuffle 5 × 30 s
• Low to moderate intensity
• Pain-free speed and stride
10-m back-and-forth grapevine 5 × 30 s
Fast foot stepping in place 3 × 30 s
Prone body bridge (forearm plank) 5 × 10 s
Side body bridge (plank) 5 × 10 s on each side
Supine bent-knee bridge 10 × 5 s
Standing single-leg balance 4 × 20 s for each limb
• Progressing from eyes open to eyes closed
• Lean forward slightly
• Moderate intensity
10-m back-and-forth sidestep shuffle 6 × 30 s
• Moderate to high intensity
10-m back-and-forth boxer shuffle 4 × 30 s
Rotating body bridge (hand plank) 2 × 10 repetitions on each side
• 5-s hold on each side
Supine bent-knee bridge with walk-outs 3 × 10 repetitions
1. Begin with knees very bent
2. Holding hips up entire time, alternate small steps out with feet, decreasing
knee flexion
Single-leg windmill touches without weight 4 × 8 repetitions per arm per lower limb
Lunge walk with trunk rotation, opposite-hand toe touch, and T lift 2 × 10 steps per limb
• Hip flexed such that the chest and back leg are parallel to the ground as the toe
reaches to the opposite foot
Single-leg balance with forward trunk lean and opposite-leg hip extension 5 × 10 s per limb
43-05 Silder.indd 296 4/17/2013 3:49:46 PM

APPENDIX A
Exercises Sets
Phase 3 30-m back-and-forth sideshuffle 6 × 30 s
(continued) • Moderate to high intensity
10-m back-and-forth boxer shuffle 4 × 30 s
Forward/backward accelerations 6 × 30 s
• Pain-free progression from 5 m to 10 m to 20 m
Rotating body bridge with dumbbell 2 × 10 repetitions
• 5-s hold on each side
• 1.4 to 3.6 kg (3-8 lb) based on individual body weight and ability
Supine single-leg chair bridge 3 × 15 repetitions
1. 1 leg on a high chair with hip flexed
2. Raise hips, lower, and repeat
• Progress from slow to fast speed
Single-leg windmill touches with dumbbells 4 × 8 repetitions per arm per lower limb
Lunge walk with trunk rotation, opposite-hand toe touch, and T lift 2 × 10 steps per limb
• Hip flexed such that the chest and back lower limb are parallel to the ground as the
toe reaches to the opposite foot
Symptom-free individual practice of sport, avoiding sprinting and high-speed
maneuvers
APPENDIX B
The progressive running and eccentric strengthening program consisted of 3 phases. The program was designed to last approximately 2 to 6 weeks but
progressed on a subject-specific basis, using criteria as indicated. Intensity was used to guide the stationary biking and agility exercises. Descriptions of
the intensity levels were given to athletes and assessed qualitatively during the activity. Low intensity was described as little to no exertion; this intensity
can be thought of as primarily used to create motion. Moderate intensity was described as that above daily activity, with some perceived exertion. High
intensity was described as a perceived exertion near that of competitive sports.
Exercises Sets
• Low intensity
Increasing-effort hamstring isometrics 10 × 10 s at 3 knee flexion angles
• Submaximal to maximal (30°, 60°, 90°)
Bilateral supine heel slides 15 repetitions
1. Lie supine on slippery surface
2. Slide heels to buttock and back out
Progressive running program (APPENDIX C)
43-05 Silder.indd 297 4/17/2013 3:49:46 PM

[ research report ]
APPENDIX B
Exercises Sets
• Moderate intensity
Prone hamstring curls 3 × 12 repetitions, injured limb only
• Prone with hip flexed at edge of a table (chest and stomach on the table)
• Use ankle weights or resistance band
Prone hip extension off edge of bed or table through full range of motion (chest and 3 × 12 repetitions, injured limb only
stomach on the table)
• Use ankle weights or resistance band
Prone leg lift and knee curl 2 × 12 repetitions, injured limb only
1. Lift straight leg slightly off floor (extend hip)
2. Flex knee without dropping leg
Progressive running program (APPENDIX C)
Nordic hamstring drop-curl progression 3 times per week; (1) 2 × 5 to 8
• Complete 2 pain-free sessions before progressing to next level repetitions, drop only; (2) 3 × 5 to 8
• Complete all 3 sessions, drop only, then progress through sessions again with drop repetitions, drop only; (3) 3 × 9 to 12
and curl repetitions, drop only
Prone foot catches with ankle weight 2 × 10 to 20 repetitions, injured limb only
1. Lie prone with hip flexed at edge of table
2. Lift leg until parallel with table
3. Drop leg quickly
4. Try to slow the fall and pause just before foot hits the floor
Prone hip extension off the edge of bed or table for full range of motion 2 × 10 to 20 repetitions, injured limb only
• Use ankle weight
1. Lift leg parallel to the floor
2. Drop and catch before leg touches floor
Standing 1-leg foot catches 2 × 20 repetitions, injured limb only
1. Stand against the wall
2. Repeat the swing phase of sprinting, pausing just prior to full hip flexion, with the
knee extended
Symptom-free individual practice of sport, avoiding sprinting and high-speed
maneuvers
43-05 Silder.indd 298 4/17/2013 3:49:47 PM

APPENDIX C
PROGRESSIVE RUNNING SCHEDULE

Exercises
• 5 min of gentle stretching before and after each session, 3 × 20 s each
- Standing calf stretch
- Standing quadriceps stretch
- Half kneeling hip flexor stretch
- Groin or adductor stretch
- Standing hamstring stretch
• Repeat each level 3 times, progressing to the next level when pain free
• Maximum of 3 levels per session
• On the following session, start at the second-highest level completed
• Ice after each session, 20 min
Constant Speed (Maximum,

Acceleration Distance, m 75% Speed) Distance, m Deceleration Distance, m
Level 1 40 20 40
Level 2 35 20 35
Level 3 25 20 25
Level 4 20 20 20
Level 5 15 20 15
Level 6 10 20 10
Constant Speed (Maximum,
Acceleration Distance, m 95% Speed) Distance, m Deceleration Distance, m
Level 7 40 20 40
Level 8 35 20 35
Level 9 25 20 25
Level 10 20 20 20
Level 11 15 20 15
Level 12 10 20 10
VIEW Videos on JOSPT’s Website

Videos posted with select articles on the Journal’s website (www.jospt.org)
show how conditions are diagnosed and interventions performed. For a
list of available videos, click on “COLLECTIONS” in the navigation bar in the
left-hand column of the home page, select “Media”, check “Video”, and
click “Browse”. A list of articles with videos will be displayed.
43-05 Silder.indd 299 4/17/2013 3:49:47 PM

[ research report ]
MICHAEL P. REIMAN, PT, DPT, OCS, SCS, ATC, FAAOMPT, CSCS1 • JANICE K. LOUDON, PT, PhD, SCS, ATC, CSCS1 • ADAM P. GOODE, PT, DPT, PhD1
Diagnostic Accuracy of Clinical Tests

for Assessment of Hamstring Injury:
A Systematic Review
H
amstring injuries are one of the most common soft tissue hamstring injury has tradition-
injuries in athletes.4,8-10,31,35,44 Treatment and management ally relied on combinations of
pain with palpation of the in-
of hamstring injuries,20,24,25 as well as injury prevention
jured area, traditional manual
and return to sport,1,4,6,16,30,32 have received significant muscle testing, passive straight
research effort in the past 10 years. Examination of athletes with leg raise testing,3-6,12,24,41 magnetic
resonance imaging (MRI),4,5,34,38,41 and
isokinetic testing.34 However, the studies
TTSTUDY DESIGN: Systematic literature review. potential articles, of which only 3 articles met the
on diagnostic accuracy of palpation, tra-
TTBACKGROUND: The diagnosis of a hamstring inclusion criteria, with only 1 of these 3 articles be-
ditional manual muscle testing, and leg
injury has traditionally relied on various clinical ing of high quality. Two of the studies investigated a
single special test, whereas the third article exam- raise testing have not provided sufficient
measures (eg, palpation, swelling, manual resis-
tance), as well as the use of diagnostic imaging. ined a composite clinical assessment employing information to quantify the clinical abil-
But a few studies have suggested the use of various special tests. The SN values ranged from ity of these tests to differentiate between
specific clinical tests that may be helpful for the 0.55 (95% confidence interval [CI]: 0.46, 0.69) for those with and without confirmed ham-
diagnostic process. the active range-of-motion test to 1.00 (95% CI: string injury. In addition, some of these
TTOBJECTIVE: To summarize the current 0.97, 1.00) for the taking-off-the-shoe test. The SP tests have been described only for assess-
literature on the diagnostic accuracy of ortho- values ranged from 0.03 (95% CI: 0.00, 0.22) for
ment of readiness for return to sport.2-5
paedic special tests for hamstring injuries and to the composite clinical assessment to 1.00 (95%
CI: 0.97, 1.00) for the taking-off-the-shoe test, ac- MRI4,5,34,38,41 and ultrasonography
determine their clinical utility.
(US) are considered the criterion refer-
TTMETHODS: A computer-assisted literature
tive range-of-motion test, passive range-of-motion
test, and resisted range-of-motion test. The use ence standards for diagnosis of ham-
search of the MEDLINE, CINAHL, and Embase
databases (along with a manual search of grey
of a single special test demonstrated stronger SP string injuries.7,13,38 However, both MRI
than SN properties, whereas the composite clinical and US are not practical alternatives
literature) was conducted using key words related
to diagnostic accuracy of hamstring injuries. assessment demonstrated stronger SN than SP for diagnosis of hamstring injury due to
To be considered for inclusion in the review, the properties.
the high incidence of this injury and the
study required (1) patients with hamstring or TTCONCLUSION: Very few studies have investi- costs associated with these diagnostic
posterior thigh pain; (2) a cohort, case-control, gated the utilization of clinical special tests for the tests. Therefore, clinical tests with strong
or cross-sectional design; (3) inclusion of at diagnosis of hamstring injuries. Further studies
least 1 clinical examination test used to evaluate psychometric properties for use in diag-
of higher quality design are suggested prior to
hamstring pathology; (4) comparison against an advocating independent clinical utilization of these
nosing this condition are needed. The
acceptable reference standard; (5) reporting of special tests. purpose of this study was to conduct a
diagnostic accuracy of the measures (sensitivity
TTLEVEL OF EVIDENCE: Diagnosis, level 3b. J
systematic review of the literature report-
[SN], specificity [SP], or likelihood ratios); and (6)
Orthop Sports Phys Ther 2013;43(4):222-231. Epub ing on the diagnostic accuracy of clinical
publication in English. SN, SP, and positive and
negative likelihood ratios were calculated for each 14 January 2013. doi:10.2519/jospt.2013.4343 tests that have been proposed to be help-
TTKEY WORDS: diagnosis, sensitivity, specificity,
diagnostic test. ful in the diagnosis of hamstring injury.
TTRESULTS: The search strategy identified 602 strain The studies included had cohort, case-
control, and/or cross-sectional designs
1
Doctor of Physical Therapy Division, Department of Community and Family Medicine, Duke University School of Medicine, Durham, NC. The authors certify that they have no
affiliations with or financial involvement in any organization or entity with a direct financial interest in the subject matter or materials discussed in the manuscript. Address
correspondence to Dr Michael P. Reiman, Duke University School of Medicine, Duke University Medical Center, Doctor of Physical Therapy Division, DUMC 104002, 2200 West
Main Street, Suite B 230, Durham, NC 27705. E-mail: reiman.michael@gmail.com t Copyright ©2013 Journal of Orthopaedic & Sports Physical Therapy
222 | april 2013 | volume 43 | number 4 | journal of orthopaedic & sports physical therapy
43-04 Reiman.indd 222 3/20/2013 1:40:48 PM

TABLE 1 Quality Assessment of the Studies Included in the Review
Item*
Article 1 2 3 4 5 6 7 8 9 10 11 12 13 14 Total
Cacchio et al11 N/U Y Y N/U Y Y Y Y Y N/U N/U Y N/U N/U 8
Schneider-Kolsky et al37 Y Y Y Y Y Y Y Y Y Y N/U Y N/U Y 12
Zeren and Oztekin45 N/U N/U Y N/U Y Y Y Y N/U N/U N/U Y N/U N/U 6
Abbreviations: N, no; U, unclear; Y, yes.
*Item 1: was the spectrum of patients representative of those in clinical practice? Item 2: were selection criteria clearly described? Item 3: is the reference stan-
dard likely to classify the target condition correctly? Item 4: is the period of time between the reference standard and index test acceptable? Item 5: did the whole
sample of patients receive verification using the reference standard? Item 6: did patients receive the same reference standard regardless of the index test result?
Item 7: was the reference standard independent of the index test? Item 8: was the execution of the index test described in sufficient detail for replication? Item 9:
was the execution of the reference standard described in sufficient detail for replication? Item 10: were the index test results interpreted without knowledge of the
reference standard? Item 11: was the reference standard interpreted without knowledge of the results of the index test? Item 12: were the same clinical criteria
available when test results were interpreted as would be in clinical practice? Item 13: were uninterpretable/intermediate test results reported? Item 14: were
withdrawals from the study explained?
that enabled comparison of the diagnos- the search. Because computerized search [SP], positive likelihood ratio [+LR], and
tic accuracy of clinical tests to their ap- results for diagnostic accuracy data fre- negative likelihood ratio [–LR]); and (6)
propriate criterion reference standards. quently omit relevant articles,19 the ref- the study was published in English.
erence lists of all selected publications An article was excluded if (1) the re-
METHODS were checked to retrieve relevant pub- ported pathology was associated with a
lications that were not identified in the condition located elsewhere (eg, lumbar
T
he PRISMA guidelines were uti- computerized search. The grey litera- spine) that referred pain to the ham-
lized during the search-and-re- ture, which included publications, post- string/posterior thigh, (2) the study did
porting phase of this review. The ers, abstracts, or conference proceedings, not provide either SN or SP data, (3) the
PRISMA statement includes a 27-item was hand searched. The reference lists clinical examination test was performed
checklist designed to be used as a ba- and grey literature were searched by 1 under any form of anesthesia or on ca-
sis for reporting systematic reviews of author (M.P.R.). To identify relevant ar- davers, (4) the study used specialized
randomized trials, 33 but can also be ticles, titles and abstracts of all identified instrumentation not readily available to
applied to multiple forms of research citations were independently screened all clinicians, and (5) the study was per-
methodologies.40 by both authors. Full-text articles were formed on infants/toddlers.
retrieved if the abstract provided insuf- All criteria were independently ap-
Search Strategy ficient information to establish eligibility plied by both reviewers to the full text of
A systematic, computerized search of or if the article passed the first eligibility the articles that passed the first eligibil-
the literature in the MEDLINE, CI- screening. ity screening. Disagreements among the
NAHL, and Embase databases was reviewers were discussed and resolved
conducted in February 2012. The Selection Criteria during a consensus meeting.
MeSH search string in MEDLINE was Articles examining clinical tests for ham-
(((hamstring[ti] OR semitendinosus[ti] string injuries were eligible if they met Quality Assessment
OR semimembranosus[ti] OR “poste- all of the following criteria: (1) patients The Quality Assessment of Diagnostic
rior thigh”[ti] OR “biceps femoris”[ti])) presented with hamstring or posterior Accuracy Studies (QUADAS) tool43 was
AND ((strain) OR strained OR (tear) thigh pain; (2) a cohort, case-control, used to determine the quality of the stud-
OR tears OR (injury) OR injuries AND or cross-sectional design was used; (3) ies. The QUADAS consists of 14 items
“evaluation” OR “physical examination” the study included at least 1 clinical ex- (TABLE 1), each with response categories of
OR “orthopedic clinical examination” amination test to evaluate hamstring yes, no, or unclear. A yes score indicates
OR diagnosis OR diagnose)) NOT (“cru- pathology; (4) the results of the clinical sufficient information, with bias consid-
ciate ligament”[ti] OR “ACL”[ti] OR test were compared against an acceptable ered unlikely; a no score indicates suffi-
“PCL”[ti]), with limits for English lan- reference standard (MRI or US)7,13,38; (5) cient information, but with potential bias
guage and humans. Two authors (M.P.R. the study reported diagnostic accuracy of from inadequate design or conduct; and
and J.K.L.) independently performed the measures (sensitivity [SN], specificity an unclear score indicates that the article
journal of orthopaedic & sports physical therapy | volume 43 | number 4 | april 2013 | 223
43-04 Reiman.indd 223 3/20/2013 1:40:49 PM

[ research report ]
or methodology provided insufficient
information or the methodology was un- Identification
clear. The total score was a count of all of
915 abstracts identified through 8 abstracts identified through
the criteria that scored yes (valued as 1, MEDLINE (n = 596), CINAHL hand search
whereas no and unclear scores were val- (n = 143), and Embase (n = 176)
ued as zero), with a maximum attainable
score of 14. The methodological quality of
each of the studies was independently as-
sessed by both reviewers. Disagreements 602 titles included after
were discussed and resolved during a duplicates removed
consensus meeting. Qualitatively, stud-
ies that exhibit higher QUADAS values Screening
are associated with less risk of design bias
than those with lower values. Similar to
576 abstracts rejected because
previously published reviews, the stud- 602 titles screened
each did not reflect diagnosis
ies were stratified as “high quality/low
risk of bias” if their QUADAS score was
18 articles rejected for providing
10 or greater or as “low quality/high risk quantitative numbers that did
of bias” if their QUADAS score was less 26 abstracts screened
not allow measurement of
than 10.23 sensitivity or specificity
Data Extraction
5 articles rejected for failing to
One author (M.P.R.) independently calculate diagnostic accuracy or
gathered data regarding study popula- 8 full text articles screened failing to report both sensitivity
tion, setting, special test performance, and specificity
pathology, diagnostic reference standard,
Inclusion
and number of true positives, false posi-
tives, false negatives, and true negatives 3 studies included in the
for calculation of SN, SP, +LR, and –LR qualitative analysis
when these were not provided. The other
authors (J.K.L. and A.P.G.) verified data
FIGURE. Flow diagram for study inclusion.
extraction accuracy once completed. Cell
counts of zero are common in diagnostic
accuracy studies, and in such instances mula (1 – SN)/SP. The higher the +LR RESULTS
0.5 was added to all cells, as suggested and the lower the –LR, the greater the
by Cox.15 SN is defined as the percentage posttest probability is altered. Posttest Selection of Studies
T
of people who test positive for a specific probability can be altered to a minimal he systematic search through
disease among a group of people who degree with +LRs of 1.0 to 2.0 or –LRs MEDLINE, CINAHL, and Em-
have the disease. SP is the percentage of 0.5 to 1.0, to a small degree with +LRs base netted 915 abstracts, and
of people who test negative for a specific of 2.0 to 5.0 or –LRs of 0.2 to 0.5, to a 8 additional papers were identified
disease among a group of people who do moderate degree with +LRs of 5.0 to through an extensive hand search. In
not have the diagnosis/disorder. A +LR is 10.0 and –LRs of 0.1 to 0.2, and to a total, 602 titles were initially retained
the ratio of a positive test result in people large and almost conclusive degree with after duplicates were removed. Ab-
with the pathology to a positive test re- +LRs greater than 10.0 and –LRs less stract and full-text review reduced the
sult in people without the pathology. A than 0.1. Pretest probability is defined as acceptable papers to 3 ( FIGURE, TABLE 2).
+LR identifies the strength of a test in the probability of the target disorder be- The sample sizes of the 3 studies were
determining the presence of a finding, fore a diagnostic test result is known. It 46, 11 140,45 and 58 37 athletes, respec-
and is calculated by the formula SN/(1 – represents the probability that a specific tively. Cacchio et al11 and Zeren and
SP). A –LR is the ratio of a negative test patient with a specific past history, pre- Oztekin45 investigated individual spe-
result in people with the pathology to a senting to a specific clinical setting with a cial tests, whereas Schneider-Kolsky
negative test result in people without the specific symptom complex, has a specific et al 37 employed a composite clinical
pathology, and is calculated by the for- diagnosis.26 assessment.
43-04 Reiman.indd 224 3/20/2013 1:40:50 PM

Puranen-Orava test, 0.86 (95% CI: 0.78,
TABLE 2 Summary of Studies Included in the Review 0.93) for the bent-knee stretch test, and
0.88 (95% CI: 0.82, 0.94) for the modi-
fied bent-knee stretch test. The Puranen-
Author/Test Subjects Sport Symptom Duration Orava test was determined to have an SP
Cacchio et al11 46 symptomatic athletes (mean Sprinters, distance 15.0  7.2 mo of 0.82 (95% CI: 0.68, 0.92) and an SN
• Puranen-Orava test  SD age, 22.8  2.3 y; height, runners, long jumpers, of 0.76 (95% CI: 0.61, 0.87). The bent-
• Bent-knee stretch test 1.79 m; weight, 76.8  11.3 kg; hurdlers, soccer and
knee stretch test had SN and SP values of
• Modified bent-knee 12 females, 34 males) rugby players
stretch test 46 asymptomatic athletes (mean 0.84 (95% CI: 0.71, 0.93) and 0.87 (95%
 SD age, 23.2  1.8 y; height, CI: 0.73, 0.95), respectively. The modi-
1.78 m; weight, 75.9  12.6 kg; fied bent-knee stretch test had SN and SP
11 females, 35 males) values of 0.89 (95% CI: 0.76, 0.96) and
Zeren and Oztekin45 140 professional male soccer Soccer Examined between 0 0.91 (95% CI: 0.79, 0.97), respectively.
• Taking-off-the-shoe players (age range, 17-33 y) with and 42 d from injury
Zeren and Oztekin45 examined 4 in-
test a history and clinical findings
• Active range- of a proximal hamstring muscle dividual special tests for proximal ham-
of-motion test strain injury string muscle strain injury in 140 male
• Passive range- professional soccer players: the taking-
of-motion test off-the-shoe test, active range-of-motion
• Resisted range-
test, passive range-of-motion test, and
of-motion test
resisted range-of-motion test. The crite-
Schneider-Kolsky et al37 58 professional footballers who Professional footballers Examined within 3 d
• Composite clinical received a diagnosis from the playing in the Austra- of injury rion standard utilized by the authors was
assessment trainer or physician of an acute lian Football League US. Reliability of the tests was not de-
hamstring injury (mean  SD termined in this study. SP for all of these
age, 24  3.8 y; height, 186.3 tests was 1.00 (95% CI: 0.97, 1.00). All
 6.0 cm; weight, 87.9  8.7 kg)
140 noninvolved legs (control side) tested
negative, resulting in an SP of 1.00 (95%
Quality Scores tation without knowledge of index test CI: 0.97, 1.00) for all of these tests.45 The
The kappa value between testers for the results), 13 (uninterpretable test results), SN for these tests ranged from 0.55 (95%
overall score using the QUADAS was and 14 (explanation of withdrawals). CI: 0.46, 0.63) for the active range-of-
0.68 (95% confidence interval [CI]: motion test to 1.00 (95% CI: 0.97, 1.00)
0.44, 0.91), with this point estimate re- Diagnostic Clinical Tests for the taking-off-the-shoe test.
flecting substantial agreement.27 Of the Schneider-Kolsky et al37 and Cacchio et Schneider-Kolsky et al37 investigated
individual items of the QUADAS, items al11 used MRI as the reference standard, the diagnostic accuracy of a composite
1, 3, 5, 6, 7, 8, 12, and 14 had 100% agree- whereas Zeren and Oztekin,45 the study clinical assessment in 58 professional
ment; and items 2, 4, 9, 10, 11, and 13 had with the lowest score on the QUADAS, footballers (rugby) with hamstring inju-
83% agreement between raters. Quality used diagnostic US. Based on recent ad- ries, with a positive test result being the
scores for each of the studies are shown in vances in technology, diagnostic US is reproduction of the patient’s concordant
TABLE 3. Using our previously estab- now considered comparable to MRI for pain/stiffness during any of the 3 indi-
lished stratification of the QUADAS, the the diagnosis of muscle injury.7,13,38 Seven vidual tests. Reliability of the testing was
Schneider-Kolsky et al37 article was con- individual special tests were investigated not investigated. The composite clinical
sidered of high quality/low risk of bias, in the Cacchio et al11 and Zeren and Oz- assessment had an SN of 0.95 (95% CI:
whereas the Cacchio et al11 and the Zeren tekin45 studies. Schneider-Kolsky et al37 0.83, 0.99) and an SP of 0.03 (95% CI:
and Oztekin45 articles had a QUADAS used a composite method based on the 0.00, 0.22).
score of less than 10 points, suggesting interpretation of 3 special tests (TABLE 3,
low quality/high risk of bias (TABLE 3). The APPENDIX). DISCUSSION
most poorly scored items of the QUADAS Cacchio et al11 examined the Puranen-
O
were items 1 (spectrum representative of Orava, bent-knee stretch, and modified ur study investigated the diag-
those in clinical practice), 4 (time period bent-knee stretch tests in 46 symptom- nostic accuracy of selected ortho-
between reference standard and index atic and 46 asymptomatic athletes. The paedic special tests for hamstring
test), 10 (index test results interpretation interrater reliability of the tests, based injury. There were only 3 studies illus-
without knowledge of reference stan- on intraclass correlation coefficients, trating tests that included both SN and
dard), 11 (reference standard interpre- was 0.84 (95% CI: 0.72, 0.87) for the SP values. Our review also found limited
43-04 Reiman.indd 225 3/20/2013 1:40:51 PM

[ research report ]

Summary of Studies Reporting on the Diagnostic Accuracy
TABLE 3
of Orthopaedic Special Tests for Hamstring Pathologies*
Author/Test SN SP +LR –LR QUADAS ICC

Cacchio et al11 … … … … 8 …
Puranen-Orava test 0.76 (0.61, 0.87) 0.82 (0.68, 0.92) 4.2 (NR) 0.29 (NR) … 0.84 (0.72, 0.87)
Bent-knee stretch test 0.84 (0.71, 0.93) 0.87 (0.73, 0.95) 6.5 (NR) 0.18 (NR) … 0.86 (0.78, 0.93)
Modified bent-knee stretch test 0.89 (0.76, 0.96) 0.91 (0.79, 0.97) 9.9 (NR) 0.12 (NR) … 0.88 (0.82, 0.94)
Zeren and Oztekin45† … … … … 6 …
Taking-off-the-shoe test 1.00 (0.97, 1.00) 1.00 (0.97, 1.00) 280.0 (17.6, 4454.6) 0.00 (0.00, 0.06) … NR
Active range-of-motion test 0.55 (0.46, 0.63) 1.00 (0.97, 1.00) 154.6 (9.7, 2468.7) 0.50 (0.38, 0.54) … NR
Passive range-of-motion test 0.57 (0.49, 0.66) 1.00 (0.97, 1.00) 160.6 (10.1, 2564.0) 0.43 (0.36, 0.52) … NR
Resisted range-of-motion test 0.61 (0.52, 0.69) 1.00 (0.97, 1.00) 170.6 (10.7, 2722.9) 0.40 (0.32, 0.49) … NR
Schneider-Kolsky et al37† … … … … 12 …
Composite clinical assessment 0.95 (0.83, 0.99) 0.03 (0.00, 0.22) 0.97 (0.88, 1.08) 1.9 (0.2, 16.0) … NR
Abbreviations: ICC, intraclass correlation coefficient for interrater reliability; –LR, negative likelihood ratio; NR, not reported; +LR, positive likelihood ratio;
QUADAS, Quality Assessment of Diagnostic Accuracy Studies; SN, sensitivity; SP, specificity.
*Values in parentheses are 95% confidence interval, except for QUADAS.
†
Diagnostic accuracy calculations reported by authors of this systematic review.
quality of these studies. The diagnostic Oztekin45 commendably investigated a Schneider-Kolsky et al37 and Zeren and
accuracy of the tests investigated in this fairly large sample of 140 male soccer Oztekin45 studies examined the more
study was quite variable, with SN values players (using the noninvolved limb as acutely injured athlete, compared to
ranging from 0.55 (95% CI: 0.46, 0.63) to a control), the study scored the lowest the Cacchio et al11 study. Therefore, the
1.00 (95% CI: 0.97, 1.00) and SP values (6/14) of the 3 studies on the QUADAS. acuteness of the injury, like the type of
ranging from 0.03 (95% CI: 0.00, 0.22) Despite the fact that the taking-off-the- injury, as previously discussed, could be
to 1.00 (95% CI: 0.97, 1.00). The paucity shoe test demonstrated 1.00 (95% CI: a confounding factor in the diagnosis of
of studies precluded meta-analysis. 0.97, 1.00) SN and SP, as well as the fact hamstring injury.
The study by Schneider-Kolsky et that the +LR and –LR values for this The assessment of posterior thigh
al,37 the only investigation that utilized test were suggestive of increasing and pain may be complex on occasion. Once
composite clinical testing, had less po- decreasing, respectively, posttest prob- red flags are ruled out (previous history
tential for bias (as demonstrated by a ability of a hamstring injury diagnosis al- of cancer, age of onset less than 20 or
higher QUADAS score) than the Cac- most conclusively, the zero cell counts for greater than 55 years old, saddle anes-
chio et al11 and Zeren and Oztekin45 stud- false positive and false negative resulted thesia, and so on),17 a detailed subjective
ies. Although this study had the highest in substantially large CIs for both likeli- history can help rule out signs and symp-
quality and least potential for bias of the hood ratio values. The other tests from toms inconsistent with hamstring injury.
3 studies in this review, it had the weak- this study demonstrated –LR values in Additionally, examination of the lumbar
est ability to determine a diagnosis. Al- the 0.4-to-0.5 range. Pretest-to-posttest spine, pelvis, and related nervous system
though this study had a high SN value of probability shifts of ruling out a diagno- may assist in ruling out these areas as
0.95 (95% CI: 0.83, 0.99), it only altered sis of hamstring injury for these other potential pain generators. Lumbar spine
the posttest probability of a diagnosis to tests would, therefore, be small and of contribution to posterior thigh–related
a degree less than minimal, with a +LR of questionable clinical utility. In contrast, pain could appropriately be ruled out
0.97 and a –LR of 1.9. The subjects in this the QUADAS scores for the Cacchio et (SN, 0.92)18 or ruled in (SP, 0.94)28 with
study were examined more acutely than al11 and Schneider-Kolsky et al37 studies repeated motions for potential lumbar
those in the Cacchio et al11 and Zeren and were higher, potentially resulting in a spine radiculopathy. Orthopaedic spe-
Oztekin45 studies (within 3 days of onset), lower risk of bias. However, the sample cial tests for this same purpose would
and the sample size was moderate com- sizes and diagnostic accuracy values in include the slump test (SN, 0.83)39 and
pared to the other 2 studies. these studies were smaller than those in straight leg raise test (SN, 0.97).42 Sac-
Sample sizes in the Cacchio et al11 and Zeren and Oztekin.45 roiliac joint dysfunction and piriformis
Schneider-Kolsky et al37 studies were As previously mentioned, the time syndrome could be ruled out with clus-
much smaller than that in the Zeren and frame from injury onset to examina- ter testing (SN, 0.91)29 and the FAIR
Oztekin study.45 Although Zeren and tion was variable in all 3 studies. The test (SN, 0.88-0.97),21 respectively, as
43-04 Reiman.indd 226 3/20/2013 1:40:53 PM

potential contributors to posterior thigh CONCLUSION terior thigh pain attributable to ham-
pain. Orthopaedic special tests for those string injury.
T
patients with suspicion of a hamstring here are a limited number of
injury would, therefore, be valuable in studies and, therefore, tests that ACKNOWLEDGEMENTS: We would like to thank
identifying those patients with a ham- investigate the diagnostic accuracy Carly Reiman for serving as a model; Holly
string injury. of orthopaedic special tests for ham- R. Thompson, BA for her review; and Leila
Hence, the clinical utility of the vari- string injury in the athletic population. Ledbetter, MLIS for assisting with the litera-
ous orthopaedic special tests investigated The diagnostic accuracy of these ortho- ture search for this study.
in this review requires careful consider- paedic special tests is quite variable. The
ation. Future studies should concentrate Puranen-Orava, bent-knee stretch, and
on investigating a set of tests with good modified bent-knee stretch tests were REFERENCES
diagnostic accuracy to either rule in or found to alter posttest probability of a
1. A rnason A, Andersen TE, Holme I, Engebretsen
rule out hamstring injury as a potential diagnosis to a small to moderate degree. L, Bahr R. Prevention of hamstring strains in
cause of posterior thigh pain. Such tests, The taking-off-the-shoe test was found elite soccer: an intervention study. Scand J
singly or in a cluster, could then comple- to alter posttest probability to an almost Med Sci Sports. 2008;18:40-48. http://dx.doi.
org/10.1111/j.1600-0838.2006.00634.x
ment other tests that have been shown to conclusive degree, although the study
2. Askling C, Saartok T, Thorstensson A. Type
be useful to identify posterior thigh pain investigating this test demonstrated the of acute hamstring strain affects flexibility,
due to the lumbar spine, sacroiliac joint, potential for significant bias. The use of strength, and time to return to pre-injury level.
and piriformis syndrome, as previously a composite clinical assessment, although Br J Sports Med. 2006;40:40-44. http://dx.doi.
org/10.1136/bjsm.2005.018879
mentioned. The diagnostic accuracy of demonstrating high SN, only alters post-
3. Askling CM, Nilsson J, Thorstensson A. A new
these hamstring injury orthopaedic spe- test probability to a degree less than hamstring test to complement the common
cial tests would better be determined by minimal. Caution should be used when clinical examination before return to sport after
future investigations with less bias. Fu- utilizing orthopaedic special tests for the injury. Knee Surg Sports Traumatol Arthrosc.
2010;18:1798-1803. http://dx.doi.org/10.1007/
ture studies controlling for injury acute- diagnosis of hamstring injury, as diag-
s00167-010-1265-3
ness assessment, blinding the results of nostic accuracy of these tests is not well 4. Askling CM, Tengvar M, Saartok T, Thorstensson
diagnostic imaging, and reporting the established. A comprehensive clinical ex- A. Acute first-time hamstring strains during
reasons for study participant withdrawal amination for diagnosis of posterior thigh high-speed running: a longitudinal study includ-
ing clinical and magnetic resonance imaging
would help limit this bias. pain attributable to hamstring injury that
findings. Am J Sports Med. 2007;35:197-206.
excludes other potential pain generators, http://dx.doi.org/10.1177/0363546506294679
Limitations versus reliance on these tests alone for 5. Askling CM, Tengvar M, Saartok T, Thorstensson
A limitation of the present study is its decisive diagnostic clinical practice, is A. Acute first-time hamstring strains during
use of stratified QUADAS scores to as- suggested. t slow-speed stretching: clinical, magnetic reso-
nance imaging, and recovery characteristics.
sess study quality. Although previous Am J Sports Med. 2007;35:1716-1724. http://
studies have used QUADAS summa- KEY POINTS dx.doi.org/10.1177/0363546507303563
ry scores,14,22,23 others have cautioned FINDINGS: The findings from the few stud- 6. Askling CM, Tengvar M, Saartok T, Thorstens-
son A. Proximal hamstring strains of stretch-
against the use of a dedicated quality ies that have looked at clinical diagnosis
ing type in different sports: injury situations,
score.36 The 1 study ranked as high qual- of hamstring injury suggest that single clinical and magnetic resonance imaging
ity could have potentially been inflated, clinical examination orthopaedic special characteristics, and return to sport. Am J
as the QUADAS does not qualitatively tests demonstrate stronger diagnostic Sports Med. 2008;36:1799-1804. http://dx.doi.
org/10.1177/0363546508315892
score for sample size or a case-control than screening capability.
7. Blankenbaker DG, Tuite MJ. Temporal
design. The use of different reference IMPLICATIONS: Due to a dearth of, and changes of muscle injury. Semin Musculo
standards may be a limitation in this re- potential bias in, the current literature, skelet Radiol. 2010;14:176-193. http://dx.doi.
view, although diagnostic US has been it is apparent that there is a need for org/10.1055/s-0030-1253159
8. Brooks JH, Fuller CW, Kemp SP, Reddin DB.
suggested to be as useful as, and more high-quality diagnostic accuracy studies
Epidemiology of injuries in English profes-
cost-effective than, MRI as a reference of clinical orthopaedic special tests for sional rugby union: part 1 match injuries. Br J
standard.13,38 Additional limitations in- diagnosis of hamstring injury. Sports Med. 2005;39:757-766. http://dx.doi.
clude limiting the studies to publica- CAUTION: Very few studies have investi- org/10.1136/bjsm.2005.018135
tion in English and having only 1 author gated the application of clinical ortho-
Epidemiology of injuries in English profes-
search the grey literature and pull data paedic special tests for hamstring injury. sional rugby union: part 2 training injuries. Br
points, which increases the risk of poten- Further investigation is warranted prior J Sports Med. 2005;39:767-775. http://dx.doi.
tial error. However, the other authors did to suggesting these tests as unequivocal org/10.1136/bjsm.2005.018408
verify the data points. methods of clinical assessment for pos-
43-04 Reiman.indd 227 3/20/2013 1:40:54 PM

[ research report ]
Incidence, risk, and prevention of hamstring 23. H egedus EJ, Goode A, Campbell S, et al. Physi- 2000. Br J Sports Med. 2002;36:39-44.
muscle injuries in professional rugby union. Am cal examination tests of the shoulder: a sys- 36. R utjes AW, Reitsma JB, Di Nisio M, Smidt N,
J Sports Med. 2006;34:1297-1306. http://dx.doi. tematic review with meta-analysis of individual van Rijn JC, Bossuyt PM. Evidence of bias and
org/10.1177/0363546505286022 tests. Br J Sports Med. 2008;42:80-92. http:// variation in diagnostic accuracy studies. CMAJ.
11. Cacchio A, Borra F, Severini G, et al. Reliability dx.doi.org/10.1136/bjsm.2007.038406 2006;174:469-476. http://dx.doi.org/10.1503/
and validity of three pain provocation tests 24. Hoskins W, Pollard H. The management of cmaj.050090
used for the diagnosis of chronic proximal hamstring injury—part 1: issues in diagnosis. 37. Schneider-Kolsky ME, Hoving JL, Warren P,
hamstring tendinopathy. Br J Sports Med. Man Ther. 2005;10:96-107. http://dx.doi. Connell DA. A comparison between clinical
2012;46:883-887. http://dx.doi.org/10.1136/ org/10.1016/j.math.2005.03.006 assessment and magnetic resonance imag-
bjsports-2011-090325 25. Hunter DG, Speed CA. The assessment and ing of acute hamstring injuries. Am J Sports
12. Clanton TO, Coupe KJ. Hamstring strains in management of chronic hamstring/posterior Med. 2006;34:1008-1015. http://dx.doi.
athletes: diagnosis and treatment. J Am Acad thigh pain. Best Pract Res Clin Rheumatol. org/10.1177/0363546505283835
Orthop Surg. 1998;6:237-248. 2007;21:261-277. http://dx.doi.org/10.1016/j. 38. Slavotinek JP. Muscle injury: the role of
13. Connell DA, Schneider-Kolsky ME, Hoving JL, et berh.2006.12.002 imaging in prognostic assignment and
al. Longitudinal study comparing sonographic 26. Jaeschke R, Guyatt GH, Sackett DL. Users’ monitoring of muscle repair. Semin Musculo-
and MRI assessments of acute and healing guides to the medical literature. III. How to use skelet Radiol. 2010;14:194-200. http://dx.doi.
hamstring injuries. AJR Am J Roentgenol. an article about a diagnostic test. B. What are org/10.1055/s-0030-1253160
2004;183:975-984. the results and will they help me in caring for 39. Stankovic R, Johnell O, Maly P, Willner S. Use
14. Cook C, Hegedus E. Diagnostic utility of my patients? The Evidence-Based Medicine of lumbar extension, slump test, physical and
clinical tests for spinal dysfunction. Man Ther. Working Group. JAMA. 1994;271:703-707. neurological examination in the evaluation of
2011;16:21-25. http://dx.doi.org/10.1016/j. 27. Landis JR, Koch GG. An application of hierarchi- patients with suspected herniated nucleus
math.2010.07.004 cal kappa-type statistics in the assessment of pulposus. A prospective clinical study. Man
15. Cox DR. The Analysis of Binary Data. London, majority agreement among multiple observers. Ther. 1999;4:25-32.
UK: Methuen; 1970. Biometrics. 1977;33:363-374. 40. Swartz MK. The PRISMA statement: a guideline
16. Croisier JL, Ganteaume S, Binet J, Genty M, 28. Laslett M, Öberg B, Aprill CN, McDonald B. Cen- for systematic reviews and meta-analyses. J
Ferret JM. Strength imbalances and preven- tralization as a predictor of provocation discog- Pediatr Health Care. 2011;25:1-2. http://dx.doi.
tion of hamstring injury in professional soccer raphy results in chronic low back pain, and the org/10.1016/j.pedhc.2010.09.006
players: a prospective study. Am J Sports influence of disability and distress on diagnostic 41. Verrall GM, Slavotinek JP, Barnes PG, Fon GT.
Med. 2008;36:1469-1475. http://dx.doi. power. Spine J. 2005;5:370-380. http://dx.doi. Diagnostic and prognostic value of clinical
org/10.1177/0363546508316764 org/10.1016/j.spinee.2004.11.007 findings in 83 athletes with posterior thigh
17. Deyo RA, Rainville J, Kent DL. What can the his- 29. Laslett M, Young SB, Aprill CN, McDonald injury: comparison of clinical findings with
tory and physical examination tell us about low B. Diagnosing painful sacroiliac joints: a magnetic resonance imaging documentation
back pain? JAMA. 1992;268:760-765. validity study of a McKenzie evaluation and of hamstring muscle strain. Am J Sports Med.
18. Donelson R, Aprill C, Medcalf R, Grant W. A pro- sacroiliac provocation tests. Aust J Physiother. 2003;31:969-973.
spective study of centralization of lumbar and 2003;49:89-97. 42. Vroomen PC, de Krom MC, Wilmink JT, Kester
referred pain. A predictor of symptomatic discs 30. Lehance C, Binet J, Bury T, Croisier JL. AD, Knottnerus JA. Diagnostic value of history
and anular competence. Spine (Phila Pa 1976). Muscular strength, functional performances and physical examination in patients suspected
1997;22:1115-1122. and injury risk in professional and junior of lumbosacral nerve root compression. J Neu-
19. Doust JA, Pietrzak E, Sanders S, Glasziou PP. elite soccer players. Scand J Med Sci rol Neurosurg Psychiatry. 2002;72:630-634.
Identifying studies for systematic reviews of Sports. 2009;19:243-251. http://dx.doi. 43. Whiting P, Rutjes AW, Reitsma JB, Bossuyt PM,
diagnostic tests was difficult due to the poor org/10.1111/j.1600-0838.2008.00780.x Kleijnen J. The development of QUADAS: a tool
sensitivity and precision of methodologic filters 31. Meeuwisse WH, Sellmer R, Hagel BE. Rates and for the quality assessment of studies of diag-
and the lack of information in the abstract. J risks of injury during intercollegiate basketball. nostic accuracy included in systematic reviews.
Clin Epidemiol. 2005;58:444-449. http://dx.doi. Am J Sports Med. 2003;31:379-385. BMC Med Res Methodol. 2003;3:25. http://
org/10.1016/j.jclinepi.2004.09.011 32. Mendiguchia J, Brughelli M. A return-to-sport al- dx.doi.org/10.1186/1471-2288-3-25
20. Drezner JA. Practical management: ham- gorithm for acute hamstring injuries. Phys Ther 44. Woods C, Hawkins RD, Maltby S, Hulse M,
string muscle injuries. Clin J Sport Med. Sport. 2011;12:2-14. http://dx.doi.org/10.1016/j. Thomas A, Hodson A. The Football Association
2003;13:48-52. ptsp.2010.07.003 Medical Research Programme: an audit of inju-
21. Fishman LM, Dombi GW, Michaelsen C, et al. 33. Moher D, Liberati A, Tetzlaff J, Altman DG. ries in professional football—analysis of ham-
Piriformis syndrome: diagnosis, treatment, and Preferred reporting items for systematic reviews string injuries. Br J Sports Med. 2004;38:36-41.
outcome—a 10-year study. Arch Phys Med Reha- and meta-analyses: the PRISMA statement. 45. Zeren B, Oztekin HH. A new self-diagnostic test
bil. 2002;83:295-301. Int J Surg. 2010;8:336-341. http://dx.doi. for biceps femoris muscle strains. Clin J Sport
22. Hegedus EJ, Cook C, Hasselblad V, Goode A, org/10.1016/j.ijsu.2010.02.007 Med. 2006;16:166-169.
McCrory DC. Physical examination tests for as- 34. Orchard J, Best TM, Verrall GM. Return to play
sessing a torn meniscus in the knee: a system- following muscle strains. Clin J Sport Med.
@ MORE INFORMATION
atic review with meta-analysis. J Orthop Sports 2005;15:436-441.
Phys Ther. 2007;37:541-550. http://dx.doi. 35. Orchard J, Seward H. Epidemiology of injuries
org/10.2519/jospt.2007.2560 in the Australian Football League, seasons 1997- WWW.JOSPT.ORG
43-04 Reiman.indd 228 3/20/2013 1:40:55 PM

APPENDIX
DESCRIPTION OF THE ORTHOPAEDIC SPECIAL TESTS
Test Description Positive Finding Illustration

Puranen-Orava test • This test entails actively stretching the ham- Exacerbation of the patient’s
string muscles in the standing position with symptoms.
the hip flexed at about 90°, the knee fully
extended, and the foot on a solid support
surface.
Puranen-Orava test.
Bent-knee stretch • T he patient is supine. The hip and knee of the Exacerbation of the patient’s
test symptomatic limb are maximally flexed, and symptoms.
the clinician slowly straightens the knee while
keeping the hip flexed.
Modified bent-knee • The patient lies in the supine position with the Exacerbation of the patient’s
stretch test lower extremities fully extended. The clinician symptoms.
grasps the symptomatic limb behind the heel
with one hand and at the knee with the other.
The clinician maximally flexes the hip and
knee, and then rapidly straightens the knee.
Modified bent-knee stretch test, start

position and finish position.
43-04 Reiman.indd 229 3/20/2013 1:40:56 PM

[ research report ]
APPENDIX

Taking-off-the-shoe • In standing, the patient is asked to take off the The feeling of a sharp pain
test shoe on the affected side with the help of his/ over the injured biceps
her other shoe. While performing this maneu- femoris.
ver, the affected leg hindfoot must press the
longitudinal arch of the noninvolved foot. The
affected leg during the maneuver is in approxi-
mately 90° of external rotation at the hip and
20° to 25° of flexion at the knee.
Taking-off-the-shoe test: posterior view.
Active range-of- • H ip extension: in prone, the patient is asked to Reproduction of patient’s

motion test actively extend the hip with an extended knee. concordant pain with
• Knee flexion: in prone, the patient is asked to either test.
flex the knee as far as he/she can.
Passive range-of- • P assive hip flexion: the patient is supine, with Reproduction of patient’s
motion test the pelvis stabilized by grasping the iliac crest. concordant pain with
As the hip is flexed, the knee is allowed to flex either test.
from the tension placed on the hamstrings and
gravity. With pressure applied proximal to the
knee joint, the normal end feel for hip flexion is
soft owing to the approximation of the quadri-
ceps with the abdomen.
• Passive knee extension: the patient is supine
with the hip flexed to 90°, with the knee flexed
in a relaxed position. The lower leg (below the
knee) is passively extended to a firm muscle
tension end point.
Resisted range-of- • H
ip extension with an extended knee: the Reproduction of patient’s
motion test patient is prone, with the knee extended and concordant pain with
the pelvis stabilized with pressure on the iliac either test.
crest. An isometric break test is performed at
end-range hip extension, with resistance ap-
plied to the popliteal fossa.
43-04 Reiman.indd 230 3/20/2013 1:40:56 PM

APPENDIX

Resisted range- • Knee flexion: the patient is prone with the knee
of-motion test extended. An isometric break test is performed
(continued) with the knee flexed to 10°, 45°, and 90° unless
contraindicated. Clinician provides resistance
over the Achilles tendon.
Composite clinical • P assive straight leg raise: with the patient’s Reproduction of patient’s
assessment lower extremity completely relaxed, the clini- concordant pain/stiffness
cian lifts the lower extremity off the plinth with during any 1 of the 3 tests.
the knee fully extended. The degree of hip flex-
ion is measured with a bubble goniometer.
• Active knee extension: the patient’s thigh is
vertical with the posterior distal aspect of the
thigh, resting lightly against a frame to keep
the thigh perpendicular to the plinth. With the
ankle relaxed in plantar flexion, the patient
is asked to actively extend the knee while
maintaining light contact with the horizontal
part of the frame. A temporary myoclonus of
alternating contraction and relaxation of the
quadriceps and hamstring muscle groups
tends to occur at the maximum angle of active
knee extension. At this point, the patient is
instructed not to force the leg past the point
of initial mild resistance. The patient is then
asked to slightly flex the knee until myoclonus
ceases. At the first point at which the shaking
ceases, the angle between the vertical and the
tibia is recorded using an inclinometer.
• Manual muscle testing: manual muscle testing
in the prone position is performed by asking
the patient to lift his/her heel by bending his/
her knee to the point at which the toe is off
the couch. The patient is asked to hold that
position while a gentle, steadily increasing
resistance is applied to the heel (about 15°
of knee flexion).
DOWNLOAD PowerPoint Slides of JOSPT Figures & Tables

JOSPT offers PowerPoint slides of figures and tables to accompany selected
articles on the Journal’s website (www.jospt.org). These slides can be
downloaded and saved and include the article title, authors, and full
citation. With each article where this feature is available, click “View Slides”
and then right click on the link and select “Save Target As”.
43-04 Reiman.indd 231 3/20/2013 1:40:57 PM

Hamstring Rehabilitation and Prevention Protocol
University of Delaware Sports and Orthopedic Clinic
PREVENTATIVE EXERCISE PROGRESSION FOR

HAMSTRING STRAIN
There are 4 components of a proper hamstring prevention program. These are
aimed to incorporate the many ways that the hamstring is used in sport where
it is most commonly injured; the muscle has the ability to stretch statically
and dynamically, contract concentrically and eccentrically and also performs
in rapid changes between the concentric and eccentric motions as in
plyometric activity.
**Before any activity, including stretching, it is important to warm up properly to increase blood
flow to the muscles for effective stretching and to reduce the risk of injury. Examples of proper
warm up include jogging, biking, jump rope, jumping jacks, etc.**
• Static stretching; should be performed for 30 seconds each with no ballistic movement
at end range.
o Pike
o Hurdles left and right
o Straddle
o Supine Hamstring stretch with belt
o Standing Hamstring stretch with anterior pelvic tilt
o Splits (gymnasts, cheerleaders, figure skaters, dancers, etc)
• Dynamic stretching; walking dynamic stretches should be performed for as many
stretches as possible within approximately 10 yards.
Walking quad stretch Walking knee to chest Frankensteins Side Lunges
Walking
hamstring stretch Helicoptors
Inch Worms
Stepping Backwards
1/15
Leg swings – these are performed stationary with

one hand supported for balance. Swing straight leg
forward until stretch is felt and then repeat into hip
extension, progressively increasing the range.
Plyometrics: These are important exercises for the prevention of hamstring strain due to
their ability to use the hamstring muscle at its greatest length and highest force. Please see
plyometric program embedded in this rehabilitative program.
• Progressive Resistive Exercises are also required to increase the strength of the
hamstring to further prevent injury.
Standing Hamstring curls Prone hamstring curls Concentric hamstring curls
Eccentric Hamstring curls Romanian Dead Lifts
2/15
REHABILITATION AND EXERCISE PROGRESSION

AFTER GRADE II HAMSTRING STRAIN
Notes:
• Muscle most commonly affected is long head of the biceps femoris, usually just
proximal to the musculotendinous junction 6-16 cm proximal to the knee joint.
• Immobilization if required should be in the lengthened position and should not
last longer than 1 week
• The use of NSAIDS is controversial in the first few days because of the potential
for impeding healing; evidence suggests that NSAIDs have no additive effect on
the healing rate.
Acute Phase (3-4 times a day)
• Rest (immobilization in a lengthened position for no longer than 1 week, then relative
rest)
o No antalgia with gait: if antalgic, supplement with assistive device
o Gentle stretching (pain less than 3/10)
• Ice in lengthened position (in long sitting with as much active pain free knee flexion and
extension as possible)
• Compression and elevation until thigh girth stabilizes
• NSAIDS no sooner than 2-4 days after injury
• Retrograde massage may be implemented for swelling control. DTM may begin when
girth is stabilized
• Modalities- sensory Estim can be used
Criteria for progression: No increase in thigh girth measured 8 cm proximal to the patella;
SLR to 80˚ with an estimation of 3 or less on a numeric rating scale where 0 = no pain and 10
= maximal pain
Test: The foot is plantar flexed and the examiner slowly (about 30˚/s) raises
the leg
Subacute Phase: day 3 to >3 weeks
• Stretching (3-4 times/day)
o Progressively increase stretch to full ROM (stretched across hip and knee)
exercises.
o Self stretching
Begin with standing technique with anterior pelvic tilt
Progress to aggressive self-stretching and partner stretches
• Strengthening progression (daily)
o Isometric knee flexion
begin with sub-maximal isometric holds at multiple joint angles (0o, 30o,
60o, 90o) and progress to maximal holds
3/15
o Stool scoots
Athlete sits on wheeled stool and plants heel into floor and uses hamstring
to propel forward. Progress with distance and to single leg.
o Start with Seated concentric isokinetic exercises (CON/ECC 50-75˚/s or isotonic)

o Move towards higher and lower speeds with more force
o Seated hamstring curls

Begin at 30% of 1RM of contralateral
hamstring 3-4 sets of 10 repetitions – progress
to 60%
• Deep Tissue Massage (daily)
o Depth and forcefulness may be increased as the
need arises to reach the target tissue that may be
deeper
• Cardiovascular fitness (up to 2 sessions per day)
o UBE
o stationary biking
o other controlled activities
• Modalities prn
Criteria for progression within this phase: Complete the activity with estimation of 3 or less
on a numeric rating scale where 0 = no pain and 10 = maximal pain.
Complete concentric seated strengthening progression and achieve full ROM with estimation
of 3 or less on a numeric rating scale where 0 = no pain and 10 = maximal pain.
Remodeling Phase: 1-6 weeks

• Stretching progression (3-4 times/day)
o Maintain or increase muscle length using aggressive frequent stretching
(passive, self and partner stretches) encourage exercise through the full ROM
• Strengthening progression (daily to every other when at power volume)
4/15
o Begin more aggressive concentric strengthening
Seated hamstring curls
• 60-80% of 1RM of contralateral leg
• Begin with strength volume (high
weight, low reps) and move to power
volume (faster speeds)
Standing hamstring curls
• Can be performed with machine or
ankle weights.
• Begin with strength volume (high weight, low reps) and move to
power volume (faster speeds)
o Prone hamstring exercises (introduces eccentric component)
Start with prone curls with ankle weights at 30% of 1RM of
contralateral hamstring 3-4 sets of 10 repetitions.
Progress to strength and power volumes
Progress to eccentric contraction via ankle weights with concentric
assistance or manual resistance.
o Manual prone eccentric/concentric hamstring curls

Athlete lays prone while manual resistance is applied distally. He/She
contracts the hamstrings concentrically against resistance and continues
to contract as resistance increases to bring the foot down eccentrically.
This allows for the athlete to be strengthened in pain free range and more
focus can be paid to weakness in certain ranges, especially closer to full
extension.
o Prone leg dropping

Athlete lies prone with knee flexed and foot in air. Gently move foot back
and forth to stimulate relaxation. Drop the foot suddenly and have athlete
catch the foot as soon as they feel it released. Progress to 1 or 2 lbs
and/or push leg instead of drop to increase loading.
5/15
This helps the athlete regain their proprioceptive sense that may have
been lost secondary to weakness and immobilization from injury. With a
heightened proprioceptive sense the athlete may be able to better detect
the position of the hamstring, which may decrease their risk of re-injury.
o Progress to seated eccentric hamstring curl

Load weights at 120 % of 1 RM of single leg hamstring curl. Use two legs
for concentric motion. Release one leg and allow single leg to release
weight in a controlled fashion. Progress weights appropriately.
Progress to prone position
o Progress to prone isokinetics (CON/ECC beginning at high speeds (240/240) and

gradually decreasing the speed (120, 90, and 60), through pain free range.
Progress to strength and power volumes
o Hamstring ball rolls
The athlete lays supine with a ball
under his/her leg(s).
Roll the ball towards the body by
flexing the leg while maintaining
trunk and hip stabilization.
This exercise can be progressed
from
• 2 feet using theraball
• 1 foot using theraball
• 1 foot using medball, other

foot in air.
6/15
o Nordic hamstrings
Athletes are kneeling with feet fixed. Instruct athlete to fall forward and use
hamstring to control descent for as long as possible then catch
themselves on the table with their hands. Athlete forcefully pushes with
hands to return to starting position to decrease concentric load to the
hamstrings. With two people begin with maximum assistance using a belt
around the athlete’s waist to assist them when they lean forward. With
one person place theraball in front of patient to allow patient to push up
and decrease the eccentric load
Progress by decreasing assistance, and increasing range until fall.
Once patient can withstand whole range of motion, increase load by
adding speed to the starting phase. The partner can also push on the
patient’s shoulder to increase difficulty. For variation person can hold
down legs with different forces to load one side more than another
Plyometric progression
In this case, plyometric exercise is used to strengthen the hamstrings while regaining the
neuromuscular properties needed to effectively perform sport specific activities.
Plyometric exercise is based on the principle of utilizing the muscle’s stretch reflex with
stores energy through its eccentric phase of contraction. If utilized quickly, the energy stored
can produce more force output during the concentric event. This brief moment between the
two phases is the amortization phase. When performing plyometric exercise it is essential to
perform a rapid eccentric phase to decrease the amortization time. They should be progressed
systematically for proper overload; typically low intensity with high volume up to high intensity
with low volume. It is also important to warm up properly in a plyometric fashion, which can be
incorporated in the dynamic warm up. An appropriate plyometric warm up for these particular
exercises include:
Marching
Jogging
Toe jogging to warm up a quick reaction time
Straight leg jogging to prepare for impact exercises
Butt kicks for stretching
Exaggerated skipping
These motions should also be progressed from 50% effort up to 100%
effort to decrease the risk of re-injury.
This list is in order from easiest to hardest and should be progressed from one to
another when completed with 100% effort while abiding by previously stated criteria for
progression.
7/15
1. Cycle split jump
a. Athlete stands in half lunge
b. Perform jump, switching feet in the air with emphasis on pulling backwards
landing with feet opposite the starting position.
c. Land and repeat jump with effort emphasized on decreasing the ground-
contact time.
2. Running Butt Kicks

a. Begin running by flexing your knee and bringing your
heel back and around to your buttocks. Maintain a
slight forward lean throughout the drill, and stay on
the balls of your feet. Complete 20 kicks within 10
yards.
b. Maintain a quick, yet shallow arm swing, keep your
elbows at 90° and drive your hands from chest to front hip pocket.
3. Running High Knees

a. Execute proper running form; keep your elbows at 90° and drive your
hands up to chin level and back to your rear pocket. Stay on the balls
of your feet, and drive your knees up as high as possible, and then
down as quickly as possible.
4. Pogo jumps with knees to butt
a. Athlete stands erect, feet comfortably
hips width apart
b. Perform straight jump and pulls heels
towards the buttocks
c. Land and repeat jump with effort
emphasized on decreasing the ground-contact time.
T
5. Rollerboard Hamstring pulls

a. Athlete lays supine with back on
rollerboard.
b. The athlete’s legs are fixed either with a partner holding them or fixed to a
stationary object.
c. The athlete then flexes and pushes away from his/her feet with emphasis
on decreasing the turn around time between flexion and extension
8/15
6. Leg Swings (bent knee and straight knee)
a. The athlete stands erect with one hand supported for balance.
b. The athlete swings his/her leg forwards until he/she feels a slight stretch
c. Quickly and powerfully push the leg down into full hip extension and let the
leg gently swing back into hip flexion with emphasis on decreasing the
time between flexion and extension.
d. This can also be done with the knee flexed to isolate the hamstrings. Start
by flexing the knee up, then extending it forward, forcefully bend the knee
downwards until almost straight, and then continue to forcefully drive the
leg up towards the butt with the knee bent. Then flex the hip to the starting
position and repeat (Claw)
7. Heel toss with med ball

a. Athlete is hanging from pull up bar with medball squeezed between his/her
heels
b. From a stand still position, the athlete throws the ball backwards with
forceful hip extension and knee flexion.
c. A partner must retrieve the ball and replace it between the athlete’s feet.
d. This exercise can be progress by using a heavier medball.
8. Box step up and jump

a. Place an 18" box in front of you. Place your right foot on top of the box.
Push off with your right foot and jump into
the air. Land in the same position as you
started. Perform the set then alternate legs.
b. Emphasize the quick contraction and
minimal ground contact time to get as high
as possible. Use your arms to help you
explode up.
c. Variations: Perform with dumbbells or Turn
180-degrees in the air and land on opposite
side of box
9/15
9. Box Jumps
a. Stand facing a 12"-18" box. Keeping your feet together, jump up onto the
box. Immediately hop back down and then explode back up in one
movement emphasizing minimal ground contact time. Use your arms
explosively to help propel you up and push off your toes.
b. Variations: Move on to higher boxes of 24" – 48". On the higher boxes
always step down do not jump.
10. Depth Jumps

a. Stand on top of a 12" box. Place a 12"-18" box about two YDS in front.
Drop down off the 12" box landing with your feet close together. Explode
up onto the 12"-18" box and stick your landing. Step down and repeat the
jump emphasizing rapid change in direction.
b. Keep your feet close together when landing on the ground or on the box.
Bend your knees when landing on the ground and use your arms to help
you explode up. Variations: Progress to higher boxes. 18" box on to 24" –
48" boxes.
11. Forward Depth Jumps in Series
a. Set up a series of 6-8 boxes 12" - 48" high and ~1 YD apart. Begin by
standing atop the first box. Drop down to the ground and then explode up
onto the second box. Continue through the series using your arms
explosively decreasing ground contact time.
b. Variations: Perform the depth jump series laterally. Perform the depth
jump series on single leg
.
10/15
12. Forward Hurdle Hops – over and back
a. Stand facing a series of 6-8 hurdles at 12"-18" high and one YD apart.
Hop over the first hurdle then over the second. As you land over the
second hurdle, immediately hop backwards over the second hurdle, then
forwards again decreasing the ground contact time. Use your arms
explosively and tuck your knees into your chest. Maintain your balance by
keeping your torso upright and your body’s center of gravity over the
hurdle.
b. Hop over the third hurdle, then the fourth, now repeat over and back hop
on the fourth hurdle. Carry on through the series performing over and back
hops every other hurdle. (Hop forwards over "odd" number hurdles; hop
over and back over "even" numbered ones.)
c. Variations: Explode into a 15-YD sprint, Go up for a header over the last
hurdle and explode into a 15-YD sprint.
• Jogging/running progression
o See attached for Field and Road Running Progression
Criteria for progression within this phase: Complete the activity with estimation of 3 or less
on a numeric rating scale where 0 = no pain and 10 = maximal pain.
Criteria for progression to next phase: Complete running progression. Able to perform 10
Nordic Hamstring exercises with minimum assist and no pain
Return to activity: 2 weeks to 6 months

• Running activities are increase from jogging at low intensity to running and finally
sprinting (please see attached running progression)
• High intensity plyometrics
• Agility and sport/position specific drills (please see attached agility reference)
MAINTAIN FLEXIBILITY AND CONTINUE PROTECTIVE ECCENTRIC PROGRAM
11/15
Field Sports Running Progression

(Distances based on 100 x 50 yard field)
Level 1 Walk ½ field then jog ½ field – repeat for 5 laps total
Level 2 Walk ½ field then jog full field – repeat for 6 laps total (~1 mile)
Level 3 Walk ½ field then jog 2 full fields – repeat for 9 laps total (~1.5 miles)
Level 4 Walk ½ field then jog 3 full fields – repeat for 9 laps total (~1.5 miles)
Level 5 Jog full 12 laps (~2 miles)
Level 6 Jog full 15 laps (~2 ½ miles)
Level 7 Jog full 18 laps (~3 miles)
** Levels 8 through 17 should be progressed to tolerance. Once at maximum level of
time suggested continue to next level abiding by criteria for progression **
Level 8 Alternate between running and jogging every field and a half
Level 9 Alternate between running and jogging every 2 fields
Level 10 Run full 18 laps (3 miles)
Level 11 Jog ½ field, then run ½ field, then sprint for width of field, then run ½ field and
repeat. – 12 laps (2 miles)
Level 12 Run ½ field then sprint a width of a field and repeat – 10 times
Level 13 Run ½ field then sprint a length of a field and repeat – 10 times
Level 14 Jog ½ field then sprint a width of a field and repeat – 10 times
Level 15 Jog ½ field then sprint a length of a field and repeat – 10 times
Level 16 Sprint width of a field then rest 2 minutes and repeat – 10 times
Level 17 Sprint length of a field then rest 2 minutes and repeat – 10
times Width - 50 yards
Length - 100 yards
Length - 100 yards
Soreness rules: (your pain)

• If sore during warm-up, take 2 days off and drop down 1 level
• If sore during workout, take one day off and drop down 1 level Width - 50 yards
• If sore after workout, stay at same level
Full Field = 300 yds
12/15
Road Running Progression

Based 12 minute jogging mile/8 minute running mile
Level 1 Walk 2 minutes then jog 2 minutes – repeat for total 35 minutes
Level 2 Walk 2 minutes then jog 3 minutes – repeat for 32 minutes
Level 5 Jog full 2 miles – 24 minutes
Level 6 Jog full 2 ½ miles – 30 minutes
Level 7 Jog full 3 miles – 36 minutes
** Levels 8 through 17 should be progressed to tolerance. Once at maximum level of

time suggested continue to next level abiding by criteria for progression **
Level 8 Alternate running for 2 minutes and jogging for 3 minutes – 30 minutes
Level 9 Alternate running for 5 minutes and jogging for 2 minutes – 28 minutes
Level 10 Run full 3 miles – 24 minutes
Level 11 Jog 2 minutes then run for 2 minutes then sprint for 30 seconds, then run 2
minutes and repeat – 30 minutes
Level 12 Run 2 minutes sprint 15 seconds and repeat – 24 minutes
Level 13 Run 2 minutes sprint 30 seconds and repeat – 24 minutes
Level 14 Jog 2 minutes sprint 15 seconds and repeat – 24 minutes
Level 15 Jog 2 minutes sprint 30 seconds and repeat – 24 minutes
Level 16 Sprint 15 seconds then rest 2 minutes – 24 minutes
Level 17 Sprint 30 seconds then rest 3 minutes – 24 minutes
Soreness rules: (your pain)

• If sore during warm-up, take 2 days off and drop down 1 level
• If sore during workout, take one day off and drop down 1 level
• If sore after workout, stay at same level
13/15
Agility Drills Progression
• Backward Running
o Run backwards, progressing distance, speed, and % effort
• Ladder High Knees
o Run through ladder with maximal hip and knee flexion increasing speed and %
effort
• Back Ladder
o Run through ladder backwards increasing speed and % effort
• Cross Ladder
o Start on L side of ladder, place R foot in ladder,
followed by L, place R foot out of ladder followed
by L. Place L foot back into ladder, followed by
R, place L foot out of ladder followed by R.
Repeat until end of ladder. Progress by
increasing speed and % effort.
• 20 Yard Square
o Start in 2 pt stance,
sprint five yards to
first cone make sharp
R cut. Shuffle R five
yards, make sharp
cut back. Backpedal
5 yds to next cone,
make sharp cut L. L shuffle through finish.
• In and Out Shuffle
o Start in 2 pt stance;
stand on side of the
ladder facing the
first box. Jump with
both feet into first
box, then back to starting position, then jump to second
box, and jump straight backwards, repeat pattern
through ladder
• Flip and Catch

o Start in standing position, placing medicine ball
tightly between both feet. Proceed to jump into
the air, kicking the ball into the air behind you.
After landing quickly turn and catch the ball
before it hits the ground.
There exercises can be modified to meet sport and positions specific demands.
14/15
References
Askling C, Karlsson J, Thorstensson A. Hamstring injury occurrence in elite soccer players
after preseason strength training with eccentric overload. Scand J Med Sci Sports. 2003
Aug;13(4):244-50.
Askling C, Saartok T, Thorstensson A. Type of acute hamstring strain affects flexibility,
strength, and time to return to pre-injury level. Br J Sports Med. 2006 Jan;40(1):40-4.
Baechle T, Earle R. Essentials of Strength and Conditioning, 2nd Edition. Hong Kong: Human
Kinetics. 2000
Brown L, Ferrigno V, Santana J. Training for speed, agility, and quickness. United States:
Human Kinetics. 2000.
Chu D. Jumping into plyometrics. United States: Leisure Press. 1992
Kaminski T, Wabbersen C, Murphy R. Concentric Versus Enhanced Eccentric Hamstring
Strength Training: Clinical Implications. J Athl Train. 1998 Jul;33(3):216-221
LaStayo P, Woolf J, Lewek M, Snyder-Mackler L, Reich T, Lindstedt S. Eccentric muscle
contractions: their contribution to injury, prevention, rehabilitation, and sport.
J Orthop Sports Phys Ther. 2003 Oct;33(10):557-71.
Mjolsnes R, Arnason A, Osthagen T, Raastad T, Bahr R. A 10-week randomized trial
comparing eccentric vs. concentric hamstring strength training in well-trained soccer
players. Scand J Med Sci Sports. 2004:14:311-317.
Peterson J, Holmich P. Evidence based prevention of hamstring injuries in sport. Br J Sports
Med. 2005 Jun;39(6):319-23.
Radcliff J, Farentinos R. High-powered Plyometrics. Champaign, IL: Human Kinetics. 1999.
Werner, Gregory A., “JMU Strength and Conditioning – Plyometric Training.” 2004
http://orgs.jmu.edu/strength/JMU_Summer_2000_WebPage/JMU_Summer_2000_Sections
/10P_Summer_Plyometric_Training_Info.htm
Worrell T. Factors associated with hamstring injuries. An approach to treatment and
preventative measures. Sports Med. 1994 May;17(5):338-45.
15/15

Final 0

Enviado por

Dados do documento

Título original

Direitos autorais

Formatos disponíveis

Compartilhar este documento

Compartilhar ou incorporar documento

Opções de compartilhamento

Você considera este documento útil?

Este conteúdo é inapropriado?

Direitos autorais:

Formatos disponíveis

Final 0

Enviado por

Direitos autorais:

Formatos disponíveis

FLEX THERAPIST CEUs

1422 Monterey Street, Suite C-102

Hamstring Strains – Prevention and Rehabilitation

1. Diagnostic Accuracy of Clinical Tests for Assessment Pages 222-231

2. Clinical and Morphological Changes Following 2 Pages 284- 299

3. Preventative Exercise Progression for Hamstring Strain Pages 1-15

Clinical and Morphological Changes

43-05 Silder.indd 284 4/17/2013 3:49:33 PM

43-05 Silder.indd 285 4/17/2013 3:49:34 PM

43-05 Silder.indd 286 4/17/2013 3:49:36 PM

43-05 Silder.indd 287 4/17/2013 3:49:37 PM

43-05 Silder.indd 288 4/17/2013 3:49:38 PM

Muscles Primary Distance From Return to Clinic Rehabilitation Compliance

43-05 Silder.indd 289 4/17/2013 3:49:39 PM

Craniocaudal Length, cm Cross-sectional Area, % Normalized Maximum T2 Hyperintensity

43-05 Silder.indd 290 4/17/2013 3:49:40 PM

43-05 Silder.indd 291 4/17/2013 3:49:41 PM

43-05 Silder.indd 292 4/17/2013 3:49:42 PM

43-05 Silder.indd 293 4/17/2013 3:49:44 PM

43-05 Silder.indd 294 4/17/2013 3:49:45 PM

43-05 Silder.indd 295 4/17/2013 3:49:45 PM

43-05 Silder.indd 296 4/17/2013 3:49:46 PM

43-05 Silder.indd 297 4/17/2013 3:49:46 PM

43-05 Silder.indd 298 4/17/2013 3:49:47 PM

PROGRESSIVE RUNNING SCHEDULE

Constant Speed (Maximum,

VIEW Videos on JOSPT’s Website

43-05 Silder.indd 299 4/17/2013 3:49:47 PM

Diagnostic Accuracy of Clinical Tests

43-04 Reiman.indd 222 3/20/2013 1:40:48 PM

43-04 Reiman.indd 223 3/20/2013 1:40:49 PM

43-04 Reiman.indd 224 3/20/2013 1:40:50 PM

43-04 Reiman.indd 225 3/20/2013 1:40:51 PM

Author/Test SN SP +LR –LR QUADAS ICC

43-04 Reiman.indd 226 3/20/2013 1:40:53 PM

43-04 Reiman.indd 227 3/20/2013 1:40:54 PM

43-04 Reiman.indd 228 3/20/2013 1:40:55 PM

DESCRIPTION OF THE ORTHOPAEDIC SPECIAL TESTS

Test Description Positive Finding Illustration

Modified bent-knee stretch test, start

43-04 Reiman.indd 229 3/20/2013 1:40:56 PM

Test Description Positive Finding Illustration

Taking-off-the-shoe test: posterior view.

Active range-of- • H ip extension: in prone, the patient is asked to Reproduction of patient’s

43-04 Reiman.indd 230 3/20/2013 1:40:56 PM

Test Description Positive Finding Illustration

DOWNLOAD PowerPoint Slides of JOSPT Figures & Tables

43-04 Reiman.indd 231 3/20/2013 1:40:57 PM

PREVENTATIVE EXERCISE PROGRESSION FOR

Leg swings – these are performed stationary with

Eccentric Hamstring curls Romanian Dead Lifts

REHABILITATION AND EXERCISE PROGRESSION

o Start with Seated concentric isokinetic exercises (CON/ECC 50-75˚/s or isotonic)

o Seated hamstring curls

Remodeling Phase: 1-6 weeks

o Manual prone eccentric/concentric hamstring curls

o Prone leg dropping

o Progress to seated eccentric hamstring curl

o Progress to prone isokinetics (CON/ECC beginning at high speeds (240/240) and

• 1 foot using theraball

• 1 foot using medball, other

2. Running Butt Kicks

3. Running High Knees

Active range-of- • H ip extension: in prone, the patient is asked to Reproduction of patient’s