For footballers, hamstring injuries remain one of the major reasons players spend time on the sideline.

The hamstrings are the group of muscles found at the back of the thigh. A strain has three levels of grading.

• Grade I, an over-stretch
• Grade II, a tear
• Grade III, which is a complete rupture of one of the three muscles

Injuries usually occur at the end of the swing phase in running, as the leg swings forward and the knee straightens. The hamstrings at this stage act to stop the forward movement of the leg and to bring the foot down.

There are certain factors that can increase the risk of getting a tear. These can include:

• Reduced flexibility
• Poor fitness and endurance
• An imbalance in strength and flexibility between the muscles in the leg
• An involvement of the back which can cause an irritation in the nerves going to the hamstrings

In order to assess and treat hamstring injuries, a distinction must be made as to whether the cause is a direct result of a specific trauma, for instance a sudden tear when striding, or is it due to a gradual dysfunction in the leg, pelvis or lower back.

For all initial injuries the immediate treatment is the RICER procedure:

• Rest. Stop running and avoid as much movement as possible to limit further injury.
• Ice the area. This cools the tissue and helps to minimise further bleeding and swelling. The protocol for icing is to apply it for 20 minutes every 2 hours for at least 48 hours. Icing has been shown to be one of the most effective ways of reducing the pain and swelling in the early stages of the injury.
• Compression using a bandage, covering the area above and below the injury.
• Elevate the leg which will also help to reduce the bleeding and thus the swelling.
• Referral. Make an appointment with a doctor or phsysiotherapist as soon as possible

Diagnosis

An accurate diagnosis is essential especially if the injury is a recurring one. An assessment by a physiotherapist or a doctor will help to determine the exact cause of any underlying problem. A CT scan and diagnostic ultrasound can help clarify this. If there is a pathology with the lumbar spine that is causing irritation in the sciatic nerve, this may be causing the pain in the hamstring to resemble a tear.

This back related hamstring strain often feels like a gradual tightening in the muscles rather than a sudden sharp pain. It often produces a constant ache even when resting, but can also be a pain only when running or kicking. A physiotherapist will be able to diagnose the problem and concentrate treatment on mobilising the joints in the lower back to take the strain off the nerves. This type of injury can be very debilitating, and if not treated early can cause many weeks out of the game. In serious cases surgery may be required as well as an early retirement from the game.

Treatment

When the cause has been determined to be coming from the muscle itself, the prescription of anti-inflammatory medication by the doctor and treatment by the physiotherapist using ultrasound and electrotherapy can help reduce inflammation and relax the muscle.

Soft tissue massage, once the bleeding has stopped will also control the formation of scar tissue. A stretching program will help to restore full range of movement. Initial stretches should be pain free and held for 20 to 30 seconds.

Rehabilitation

Rehabilitation of the injured hamstring goes further. It is essential to regain full strength in all the leg muscles once the pain has settled. This is essential to restore proper function in the lower limb. A balance in muscle strength between the quadriceps (front thigh muscles) and the hamstrings is vital.

Functional exercises are used as early as possible to avoid a loss of fitness and conditioning. For mild hamstring strains, it is now common to see the players doing light jogging after the acute stage of injury (48 hours).

This is only done if pain free and there is no striding out. When the inflammation settles gradually more difficult agility tasks are added. They may include backward, sideways and zigzag running. Straight line running is progressed gradually from ½ to ¾ then to full pace. Adding rapid accelerations and decelerations, changes in directions at speed and jumping will also make the training more specific.