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Hamstring Strains and the Lumbar Spine

Of all the conditions treated in the Sports Physiotherapy and the Sports Medicine fields, no one condition has commanded as much interest as the "hamstring strain". As early as the 1970's, Clinicians have identified the "hamstring strain" as the condition most commonly misdiagnosed, usually ascribing a local cause when, in fact, the pain is emanating from a distant cause. Often, the pain in the hamstring region was coming from the lumbar spine, sacro-iliac joint or a diseased hip joint.

What we have to ask ourselves is ..... "How can we tell the difference?"

We do know that the grading of muscle injuries can give us clues as to whether there has been damage to the muscle or not. According to what is being taught in many Physiotherapy schools around the world, the grading scheme for hamstring muscle injuries is as follows:

Grade One

Pain and tenderness in the hamstring muscle;

Decreased straight leg raise (SLR);

Decreased strength of the hamstring muscle.

Grade Two

Marked pain and tenderness in the hamstring muscle;

Spasm in the hamstring muscle;

Bruising and swelling (often later);

Marked decrease in strength of hamstrings, with pain on contraction;

Marked limitation of SLR.

Grade Three

Complete rupture;

Pain often diminished due to tearing of muscle and nerve tissue;

Marked bruising and swelling;

Often palpable gap in hamstring muscle;

Severe spasm in the remaining hamstrings;

Marked pain on contraction of hamstrings with concurrent loss of strength;

Marked loss of SLR range.

What is obvious then, is that the Grade 2 and 3 injuries demonstrate muscle tissue damage, whereas the Grade 1 injury may be a little more dubious. Numerous studies have shown that all the signs and symptoms exhibited by a Grade 1 hamstring strain can be reproduced by a referred pain syndrome from the lumbar spine.

Alot of patients, suffering from Grade 1 hamstring strain, will tell you that they "pulled" the hamstring, felt a "twinge" or "cramp" but none will show the cardinal signs of bruising or swelling that will give us the confidence to call the condition a muscle tear. What we do know is that the Grade 1 hamstring strain will present with:

tenderness in the hamstring;

pain and tightness on SLR testing;

pain and loss of strength of the hamstrings.

A test developed over 10 years ago, the Slump Test, gave Physiotherapists one avenue of differentiation. It was designed to put the entire nervous system on tension, and if, by moving a part of the body that was distant from the hamstring, this changed the symptoms, we were able to determine that the symptoms were attributable to the nerves of the spine, and not the hamstring muscle itself. In the case of Grade 1 hamstring strain, when the Slump Test was applied and it reproduced the pain from the "hamstring strain, if the neck flexion was released and the symptoms changed, the source of the symptoms was the lumbar spine and related structures and not the hamstring itself, as the hamstring and the cervical spine have no direct connection that could be altered.

In a recent study on Australian Rules football players, it was found that when players suffering from Grade 1 "hamstring strain" were treated with Slump stretching, in addition to their normal hamstring treatment, they returned to sport much quicker than the football players who only had normal hamstring treatment - on average 2 weeks earlier!

Treatment of "Hamstring Strain".

The types of treatment provided to sufferer of "hamstring strain", when other structures are implicated, include mobilisation and manipulation of the lumbar spine (when indicated), stretching of the spinal joints and muscles, massage, nerve stretches (when the Slump Test was positive and indicated) and exercises for both mobility and strength. The latter encompasses entities such as lumbar stabilisation exercises, restoration of the normal muscle balance in the spine, pelvis and lower limbs and improving co-ordination of all specific muscle groups.

The ultimate aim of all Therapists is to treat the client in the most effective manner, hence minimising the time out of their specific activity, whether it be sport or work. For this reason, treatment must be condition specific. Misdiagnosis is an all too common occurrence, leading to poor and inappropriate management. Using a logical approach to assessment and treatment of the "hamstring strain", as well as other injuries, will facilitate a painless and speedy recovery.

The concepts presented here are entirely the author's own (unless expressly stated) and do not represent the thoughts or ideas of any other person.

Brighton Spine Institute | 441 Bay Street Brighton, Victoria 3186 | AUSTRALIA | Tel. + 61 3 9596 7211 | Fax. + 61 3 9596 7871

Charlie Kornberg. All rights reserved. No part of this web page, or related accompanying pages, may be reproduced without the prior permission of the Author.