I was watching the Liverpool v Manchester United football match yesterday and was interested in the pre-match warm up the players were doing. There was lots of stretching of the hamstrings going on. Hamstring injuries are common in athletes and frequently result in long delays in return to sport. So what is the comparative effectiveness of rehabilitation approaches for hamstring injuries? It was timely that this was the topic of an updated Cochrane systematic review published in December 2012.

Here’s what they did

They searched electronic databases up to Nov 2012 for Randomised Controlled Trials (RCTs) of any therapeutic intervention or rehabilitation programme (one or more intervention, in comparison with a control or one or more alternative intervention) for hamstring injuries. Their primary outcome was return to full function (work or pre-injury level of activity or pre-injury level of sports activities) within three months.

Here’s what they found

• One trial, involving 80 elite athletes, assessed additional (four times a day) versus once daily stretching and the other assessed exercise for movement dysfunction versus stretching and strengthening. Results suggested additional stretching could reduce time to return to full activity (mean difference (MD) -1.8 days, 95% confidence interval (CI) -2.1 to -1.5, P < 0.001).
• The second trial, involving 24 participants from a diverse sporting background, did not find conclusive evidence of a difference (MD -14.5 days, 95% CI -30.64 to 1.64, P = 0.08). It did, however, report reduced re-injury rates using exercise for movement dysfunction of 8% versus 64% (odds ratio (OR) 0.05, 95% CI 0.00 to 0.52, P = 0.01).
• No other outcomes relevant to this review were reported by either study: most notably pain and participant satisfaction.

The authors concluded

“There is limited evidence to suggest that rate of recovery for elite athletes can be increased with an increased daily frequency of hamstring stretching exercises. There is preliminary evidence from a small study of mixed ability athletes to suggest that exercise to correct movement dysfunction could reduce time to return to full activity and the risk of re-injury. Until further evidence is available, current practice and widely published rehabilitation regimens cannot either be supported or refuted.”

The Musculoskeletal Elf’s view

It is interesting that in a topic such as this there appears to be a paucity of evidence. However as we are aware lack of evidence is not evidence of no effect. Within the sports literature there are may studies reported that use healthy college students as participants. The authors of this review suggest that future studies should investigate differing rehabilitation techniques and frequency and intensity of interventions on people with hamstring injuries rather than on healthy individuals.

A further issue is highlighted that of  ‘standard therapy’ it is often poorly reported in rehabilitation trials. The authors of this review also suggest that outcomes should include incidence of recurrence of injury, pain and patient satisfaction, as well as rate of recovery.

NB: Tracey Howe provided advice in developing the protocol and the first version of the above review (2007) during her role as an Editor of the Cochrane Bone, Joint and Muscle Trauma Review Group.

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Links

• Mason DL, Dickens VA, Vail A. Rehabilitation for hamstring injuries. Cochrane Database of Systematic Reviews 2012, Issue 12. Art. No.: CD004575. DOI: 10.1002/14651858.CD004575.pub3.