Hamstring strain

Chris Mallac discovers a novel solution and an unusual explanation for a stubborn hamstring strain

This patient had me perplexed for years in terms of explaining the pathophysiology of his symptoms as well as his improvement. However, a report in the British Journal of Sports Medicinethat I recently read switched on the proverbial light bulb in my head. This case study provides a possible explanation for an interesting calf/hamstring strain.

The problem

A few years ago I needed some work done to finish a deck at home and a friend offered his extensive carpentry services in exchange for some body work by me to fix his long standing calf/hamstring strain. Wanting to save myself a bit of money, I jumped at the proposed barter, thinking it would be a winning deal for me. After all, how hard could it be to fix a somewhat reluctant weekend footballer?

This particular 32 year old male had a four-year history of repetitive left calf/hamstring ‘strains’. It had all begun one weekend as an acute hamstring strain sustained during a soccer game while my friend was attempting to slide tackle an opposing player. He felt the hamstring grab around the mid-belly of the muscle. He managed it conservatively in the first instance with occasional ice, some gym strengthening exercises he had picked up on the internet and a gradual re-introduction back into running. He missed about six weeks of weekend soccer.

He continued to play over the next few years, but would consistently break down with hamstring strains and calf strains which he always tried to manage conservatively himself, never seeking a medical opinion. After his most recent calf ‘strain’, though, he decided to quit his weekend soccer exploits and concentrate on bush track running and yoga, which had recently become his consuming passion. While he continued to suffer from the occasional calf/hamstring twinge with running, these were never severe enough to stop him for any longer than a few days.

The patient

Having documented my friend’s history, my first thought was ‘back related’ hamstring problem and/or inadequate rehabilitation. On examination, my most significant findings were the following:

* Atrophied left calf (35.5cm vs 36cm) and hamstring (60cm vs 61cm).

* Pelvis – left anterior rotated, right rotated sacrum and lower lumbar levels.

* Hypertonic left TFL (tensor fascia lata), psoas, quadratus lumborum, right glutes and long adductors.

* Straight leg raise left = 90, right = 120.

* Hamstring bridge gave awareness on left with knee at 0/45/90 degrees.

* Poor hamstring endurance on left with ‘30 rep bridge test’ (see box below left). * Poor transversus abdominis activation, particularly on left side.

* Tight TFL on both sides.

* Tender trigger points through upper hamstring attachment and around short head of biceps femoris, and in mid belly of gastrocnemius.

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The treatment

With such a long list of problems, I had plenty to work on to evaluate any changes prior to sending the carpenter off for any specialist opinions or scans. I had him agree to see me for a month of treatment before we made a decision about further investigations or referrals. He also had to avoid running until I felt I had sorted out a few of the tonal and muscle imbalance issues.

Our month of treatment focused on pelvic muscle releases of the hypertonic muscles, specific muscle activation (particularly glutes and transversus), and gym-based eccentric loading of the hamstrings (Romanian dead-lifts, Nordic hamstring lowers, bridging, single-leg leg curls, step-ups, high-foot leg press). I allowed him to run from Week 2, but only according to my prescription: on flat ground and over a distance of 60m (20m acceleration, 20m steady, 20m deceleration). He started with 3 sets x 6 reps (walking for about half of the recovery phase), which we increased during the four weeks to 3 x 10 (walking was down to about 20% of recovery). He ran every second day, and eccentrically loaded in the gym on the same day as running.

At the end of the month he had achieved equal range of motion in the hamstrings, good activation of glutes and transversus, and good results on his hamstring endurance test. He was running comfortably (walking recovery down to 10%), but could never get above this speed without becoming aware of his hamstring ‘strain’ and retained a permanent awareness of low back stiffness, despite all his Iyengar yoga sessions.

I discharged him with a list of self-management techniques and he was reasonably happy as long as he could avoid sprinting. We discussed the possibility of CT or MRI scans of his spine and epidural cortisone injections, but as he was an anti-immunisation campaigner, he was going to avoid doctors and needles like the plague.

The miracle solution

My friend called me about a year later to tell me his hamstring problem had all but resolved. He was back to running without any awareness of strain or discomfort, and for the first time in years was able to sprint without blowing a calf or hamstring. He was that excited he was thinking about taking up weekend soccer again.

Being completely surprised and happy for his unexpected progress, I enquired as to what he may have done to improve his condition. A few months earlier his regular Iyengar yoga teacher had relocated, so he found another teacher, who ran an at-home yoga studio, set up with all the ropes, bells and whistles needed for full-on Iyengar yoga instruction. He believed the cure lay in one new stretch, known as ‘Rope Sirsasana’, in which the ‘victim’ hangs upside down on ropes attached to the wall with their legs abducted and externally rotated (see Figure 1 above). You have to hang and relax into this position for considerable lengths of time (up to 20 minutes). The position is designed to stretch and open the hips and lower back.

When he explained this, I reasoned that he must have had a degenerative condition of his spine that was possibly irritating the L5/S1 nerve root, ‘sparking’ up the nerve supplying the hamstring and calf. The upside-down hanging provided ‘traction’ to the spine, possibly offloading the nerve roots.

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An alternative explanation

The article presented in the British Journal of Sports Medicinein 2004 by John Orchard et al(1)has provided me with another possible explanation for the improvements experienced by my handyman friend.

Orchard et al cite a research article written in 1995 by Briggs and Chandraraj which explains how the lumbosacral ligament (an inconsistent extension of the iliolumbar ligament) may possibly compress the nerve root of the L5 nerve onto the anterior superior ridge of the sacrum. Briggs and Chandraraj showed that cadavers with a degenerative L5/S1 disc correlated highly with compression of the L5 nerve by the lumbosacral ligament. This ligament may become hypertrophic in response to degenerative changes in the spine. The important point about this pathology is that the compression of the nerve is ‘extraforaminal’: it compresses outside the known bony boundaries of the lumbar spine.

Orchard et al go on to suggest that it is feasible that this L5 nerve root compression exists in older athletes, which may explain a poor response to conventional rehabilitation after hamstring or calf injury. They propose that it is possible to inject the L5 nerve root to temporarily gain symptom relief, and they also suggest some difficult surgical options that may manage this condition.

What is interesting about this case study is that the patient’s description fits the criteria perfectly for extraforaminal entrapment. The upside-down hanging therefore provides a ‘release’ of the pressure by pulling the L5 disc and nerve away from the sacrum through the use of gravity.

Perhaps this gives temporary relief, and if done on a regular basis (and I believe my friend would perform the Rope Sirsasana almost every second day), it may give what appears to be long-lasting relief.

It would have been interesting to analyse changes in pelvic muscle imbalance, hamstring muscle tone and flexibility, and hamstring strength immediately after the rope stretch to assess for sudden changes in the presenting signs and symptoms. 1.Orchard JW, Farhart P and Leopold C (2004) ‘Lumbar spine region pathology and hamstring and calf injuries: is there a connection?’ British Journal of Sports Medicine38: 502-504