By Zhenya Kurashova Wine
Originally published in Massage & Bodywork magazine, October/November 2000.
Hamstring injuries can be extremely frustrating to the runner. Small tears that seem insignificant can lead to major problems if left untreated. Prevention is usually the best cure. Therefore, it is important that runners maintain good flexibility. A stretching program is very important. As a former coach and runner, I prefer a ballistic type of stretching which mimics the range of motion that occurs during the activity. Certain types of running drills can be an excellent form of stretching. Muscles should be thoroughly warmed before beginning any kind of stretching program. Regular massage on healthy tissues also helps maintain elasticity of the muscles, tendons and ligaments. This should help to prevent injury. If tissues are healthy and flexible, an injury, if it does occur, should be much less severe and heal quicker.
The hamstring muscle can be injured at the attachment, musculotendinous junction, or belly of the muscle. Injuries can range from total avulsion, including pulling bony attachments away, to slight tears. Sprinters are most the most likely runners to experience severe hamstring injuries due to the speed of the movement and the larger range of motion that occurs. Long distance runners are more likely to have minor tears of the first and second degree.
As a high school coach, I rarely experienced hamstring problems with my runners. I owe this to good warm-up, attention to drills after practice and massage therapy as a restorative technique. While working with Dartmouth College cross-country runners, I can recall one runner who experienced a hamstring strain. It wasn’t severe, yet it required constant attention in order for him to be competitive. He went on post-college to make the U.S. Olympic Team. He used massage, physical therapy and other techniques to stay competitive.
As a Masters runner, I experienced a total avulsion of a portion of my hamstring muscle as a result of a bicycle accident. This terminated my competitive running career. The injury caused constant cramping and very hard scar tissue. I gained incredible relief from just one 15-minute session of Russian sports massage performed by Dr. Anatoly Birukov. I was able to run without cramping for the first time in a year and a half. I still was not competitive, but at least I could do the activity that I loved again. I will require regular treatment forever to keep the scar tissue soft and elastic.
— Al Devereaux
There are several problems that occur in any muscle injury which has happened as a result of a tear. Swelling is the No. 1 issue, but if the patient was not treated properly from the start, you will also see scar tissue develop. Another condition I have come across in hamstring (and quadriceps) injuries has been calcified deposits, which present themselves as a “hard ball” in the tissue. I will outline goals, objectives and treatment protocols for situations you may encounter as a result of a severe hamstring strain. But first, let’s qualify the strain.
Strains are the injuries that occur in the muscle, not in the ligament. There are three kinds of strain: simple, moderate and severe. Simple strain occurs due to muscle overuse, and in all muscle injuries this is the one that is most often ignored. There is some pain, but it is only present when the muscle is asked to perform (I am speaking about lower extremity muscles and specifically the hamstring). Also, there are few visible symptoms present, so the simple strain often goes untreated. In moderate strain, you will see some tearing of the muscle fibers, and even slight tears of the tendons which attach the muscle. Pain is greater in moderate strain, and it is constant. The pain becomes severe as the muscle is asked to perform. Edema (or swelling) will be present in moderate strain, the area of the strain might become red (sign of inflammation), and the area will be tender to touch. In severe strain, you will see complete separation of the tendon attaching the muscle. Severe edema will be present in the area of the break, as well as in the surrounding areas.
If severe strain goes untreated, several problems will arise. First, edema leads to development of exudate. Although the term “exudate” is usually used to describe the phlegm that comes out of the lungs, the actual definition of exudate is the “by-product of inflammation.” Exudate in the muscle (or joint) feels like glue, or more dense fluid than in edema. If this exudate is not removed from the tissue, it will calcify or become hard. Secondly, scar tissue will develop in an unwanted formation in order to connect the muscle back to the tendon. This scar tissue becomes an adhesion and it will adhere to the surrounding tissue, rather than to the muscle alone.
Severe strain — Acute stage: Surgical repair is necessary for the muscle to be reattached to the tendon. You may aid in the timing of this by reducing the edema, as surgery can not take place until there is a decrease. To reduce the edema, work with gliding and vibrating strokes in the area proximal to edema: going toward the groin area for the knee attachment you may work on, the hamstring moving upwards, and for the hip attachment you will work on the buttocks going toward the groin. As the swelling goes down within your treatment, you may add vibrating strokes using your fingers on the area of edema. Make sure there is no pressure into the swollen tissue, since this will produce edema. This treatment works best if it is done for 5-7 minutes, once every hour for a day or two.
Severe strain — Sub-acute stage: If you are seeing your runner after the surgery was performed, your goals will be to decrease edema (which will still be present), to decrease pain, to promote development of healthy scar tissue, to eliminate exudate, to increase arterial blood flow to the tissue, and to increase tissue elasticity and pliability. These goals can be accomplished by using gliding and vibratory strokes in the area of the break, as well as the surrounding areas. Due to the amount of pain the client will have, do not cause any pressure in the tissue since this will increase the pain. Once the goals outlined above are accomplished, you may move on to the next stage of your treatment. This treatment is done once a day, every day, for 10-12 minutes, and is discontinued when the goals are accomplished.
Severe strain — Chronic stage: Let’s presume that you were not able to see the client for a few months after the initial injury. When the client comes to you, you will not see any edema. You will, however, see severe muscle tension. You may also see exudate (or calcification) in the area of the break, dense scar tissue or even adhesions. If this is the case, you will operate under the following set of goals: to decrease pain, to increase tissue elasticity, to reduce adhesions, to increase scar elasticity, to resolve exudate, to break down the calcified deposit, to increase tissue nourishment, to normalize muscle function, and to strengthen the muscle contraction.
To accomplish these goals you will start with gliding strokes as they will prepare the muscle for quicker recovery, as well as increase local circulation. You then should proceed to pressure stretching strokes of the hamstring itself. Use wide hand positions, such as heel of the hand or cresting hand, in order to provide deep but non-invasive touch. After a few minutes of general pressure stretching of the whole hamstring, you may move to pressure stretching of the injured area. Once again, make sure your touch is not invasive. You will have to work 2-5 minutes in the area of the break in order to increase tissue elasticity, to reduce adhesions, to increase scar elasticity and to resolve exudate. If there is a calcified deposit, you will have to work with more penetrating strokes in order to dissolve it. Use your index, middle and ring fingers to press directly onto the calcified deposit. You will feel a little ball (from the size of a ball used in jacks to the size of a softball in some cases) under your fingers. Use this direct pressure stretching for 3-5 minutes in order to produce enough heat to break up the calcification.
I want to say here that there is no way to reconstruct (or break) the scar tissue which is already present. You may increase elasticity of the scar, and thus make it more pliable and able to function as a part of the muscle. This means that if adhesions or thick scars have developed as a result of this injury, the client may have to be seen once every two weeks to maintain the pliability of the scar.
In order to accomplish the goal of normalizing muscle function, you will need to provide the muscle with an “exercise-like” stimulation. To do this, use kneading strokes, which in fact cause the muscle to contract. This treatment should be done every other day, 10-15 times, and should last 10-15 minutes. Make sure you take a day off in between each treatment so that tissue can rest and remember the information you presented it.
For moderate and simple strain, you will be following some of the goals (decrease pain, increase tissue elasticity, increase scar elasticity, increase tissue nourishment and normalize muscle function) and the treatment outlined in the chronic stage of severe strain.
IT Band Strain
The IT band gets involved during arch problems, as it tries to stabilize the calf muscles. Treatment for the IT band is similar to the hamstring treatment, as are the goals. The main difference of treating the IT band is its structure. It is made out of a lot of connective tissue and some striated muscle tissue, and thus is very tight. If the tight IT band goes untreated, it will involve the hip to which it attaches, as well as the lower back. Use heel of the hand pressure stretching techniques for 2–7 minutes, and then proceed to cresting pressure stretching for another 5 minutes for best results. You should work with the opposite hand (i.e. for the left IT band use your right hand), and move your hand in a scrubbing motion as you progress in the upward direction over the IT band. Use pressure stretching with three fingers while you work the knee and hip attachments. This condition responds quickly to treatment, but make sure the foot problem (arches in particular) is addressed (as described in earlier issues) to prevent future problems.
This article concludes our series on treatments for running injuries. In the next few issues I will address injuries of contact sports.