After 6 years of continued studying, 4 in Ireland and the latter 2 in Scotland, I returned home and successfully secured employment near to home. Leaving was a big deal for me at the time but having kept myself reasonably active while away playing Gaelic football and running more I still felt I had unfinished business on the rugby pitch. Although I hadn’t played in 5 years I still reckoned I had something to offer. And with the news of an old Kiwi house mate I played with while with Clontarf RFC taking charge of the local rugby team I thought it was the perfect opportunity to get back involved. Over a quick lunch time conversation I was surprised to find out what he remembered about me was my pace. Pace? Me? Really? I disappointed him with news that I hadn’t been doing much in the line of speed work or if I ever really possessed such an attribute. I think what he took from this was me being modest. He’d later recall that I was in fact right. Pre season opened my eyes to just how drastically the game of rugby had changed in 5 years. In my former playing days I remembered a game of running around people, keeping away from the big guys and avoiding contact as much as possible. At least that’s what I did. Now it was a game of collisions. Take the contact and reset for the next phase of play. There was more structure and planning, much less of a sporadic, on-the-spot, ‘leave it to chance’ approach. One of my first games back I chased a kicked through ball into the dead ball area in an attempt to ground the ball and announce my return to the game with a try. The geometry of the rugby ball (not for the first time in my life) deceived me. I reacted instinctively and tried to change direction while traveling at “speed” in response to an unpredictable bounce. It was on this sudden movement I experienced what patients had been reporting to me over my first few months of working in practice. That sudden sharp pain into the back of my thigh that I knew could be only one thing. And although I never experienced such pain before I knew the significance. I had just, for the first time in my life, torn my hamstring.
Hamstrings are the most commonly injured muscle group accounting for 33% of all GAA injuries, 30% of track and field but only 15% rugby injuries (bare in mind the majority of rugby injuries will be contact related). They range from minor tears (grade 1) to full ruptures (grade 3) and while thankfully I was at the lesser end of the scale it still bloody hurt. Over the course of the recent Rugby World Cup I reflected on my injury when Paul O’Connell hit the deck and guzzled on oxygen for pain relief holding his leg. He was on the other end of the scale; a grade 3 rupture requiring surgical repair. So why is this injury so prevalent and often so difficult to return to sport from?
I ticked a few of the boxes well documented as risk factors for getting this hamstring strain. I was over 23 years old (I was 25), I undoubtedly had muscle imbalances between my hamstrings and quads (still do I would say), and most significantly I was not prepared for this sudden change of direction having only been used to running predominantly uni-directional. To pass the final months of my Physiotherapy studies while battling through a research project on Parkinson Disease I started longer distance running. For me this was maybe 8-10km at the time, before I really got bitten by the running bug. I was asking my muscles to run at slower consistent paces but for more prolonged periods. They got used to this and developed a recruitment pattern of just having to tick along meeting this demand. So when that ball bounced in a direction I was not anticipating I was asking my hamstrings to contract at a rate and force they were no longer comfortable performing – to decelerate and instantaneously propel me in a direction in response to the ball. Scientifically speaking I was used to recruiting slow twitch (type 1) muscle fibres, not fast twitch (type 2). I was a sitting duck and tore biceps femoris, the most commonly injured of the hamstrings at the typical point of tearing, i.e. at the end of the swing phase when the muscle is at its most lengthened position yet still contracting.
Which of the above mentioned risk factors are modifiable? Age? Nope. Genetic make up fibre type? Nope. What you’ve got at birth is based on what you’re parents’ muscle fibre type make up is so unless you’ve been parented by 2 sprinters the chances are you won’t ever be the fastest out of the blocks. None of my siblings or cousins are particularly quick, strong or powerful, traits typical of fast twitch dominant athletes, much to my brothers denial. Our genetic make up is much more suited to endurance events backed up by family history with a grand uncle, the late Peter McArdle, a Pan American Games winner at 10,000 metres and one of Irelands finest long distance runners before moving to America. Football? Rugby? What was I thinking? But lets focus on the risk factors that we can change or influence. The main thing is strength. Many randomised control trials (the gold standard type of clinical trail) now exist in support of strength training, specifically eccentric training, in the prevention of hamstring strains. Many teams now use this as part of pre season and in-season maintenance in an attempt to eradicate hamstring tears and the results are very positive. The effect of a 10 week progressive strengthening programme has shown to decrease the incidence of injury. Flexibility funnily enough has no impact on the incidence of injury, the greatest misunderstanding of all time. All that time stretching and no real evidence to back it up. Of course it has other roles in performance and daily living for sure but not in the prevention of injury. Fatigue is the other big player. Most strains occur towards the end of a game and are also 15 times more common in games compared to training. As the muscle becomes fatigued with repeated over lengthening and contracting it is more susceptible to damage. This would suggest there should be an endurance component to rehabilitation also. Not just the importance of strength but the ability of that muscle to do the specific required activity on repeated occasions.
Getting back to play can be a balancing act, very hard to get right. The risk of re-injury as already mentioned is high particularly in the first month. Depending on the grade it will be a minimum of 3 weeks (usually more) on the sidelines. But this doesn’t mean complete cessation of activity. Relative rest initially followed by graded return and commencement of strengthening exercises. On tearing my hamstring I hobbled around Stradbally at Electric Picnic the next day (not wise). A week later I ran the Dublin half marathon. Although my stride length was decreased (something I would later discover was maybe not such a bad thing) I could handle long duration low intensity exercise, it was specifically acceleration and deceleration I could not. At 3 weeks following your typical grade 1-2 hamstring strain with commencement of rehabilitation strength can be up to 70% of the non injured leg. By 6 weeks it may still only be 90%. This risk of re-injury means monitoring is of upmost importance and instead of time based protocols for return to sport it should be guided by testing criteria such as strength, power, functional ability or limitations. There is no exact timeline for return to play but players, coaches and medical staff should ensure they are meeting the requirements of their specific sport in training before attempting a return to competition.
I got back playing and ended up in the above mentioned re-injured category doing the exact same thing 6 weeks later. I had hard wired my muscles to slow twitch mode and it was proving difficult to re-wire. And hence began my love of long distance running. Slow and steady I can handle. Through the night, over mountains I can handle. Marathon and up to 65km I’ve found out I can handle. Just don’t ask me to change speed or direction.
For more information on any of the issues addressed throughout this article please contact Rob via email at firstname.lastname@example.org, Twitter @mccabephysio, Facebook at McCabe Physiotherapy or visit http://www.mccabephysiotherapy.com
Rob McCabe MISCP
MSc (pre reg) Physiotherapy, BSc Sport Science and Health, MSc Sports Physiotherapy, PG Dip Orthopaedic Medicine
Orchard House, Moorefield Rd, Newbridge, Co. Kildare