The hamstring injury is one of football’s blights, affecting so many of our best known players. The latest is Andy Carroll who sustained the injury yesterday in his first game at West Ham – read here. The extent of the injury will be clearer following a scan. Hopefully this will be a minor insult that will be fully resolved with a rapid, yet safe return to play.
A study published this year in the BMJ looked at the use of the MRI scan as a prognostic tool for lay-off after hamstring injuries in professional footballers and the association between the MRI findings and injury circumstances. It was found that: ‘70% per cent of hamstring injuries seen in professional football are of radiological grade 0 or 1, meaning no signs of fibre disruption on MRI, but still cause the majority of absence days’. This is an interesting point as it demonstrates that significant time out of football for hamstring problems is not underpinned by serious tissue damage. We know that pain is not an accurate indicator of tissue damage and certainly I have seen many patients who experience repeated injury, yet there is no clinical evidence for an inflammatory response, the early stage of healing.
The seriousness of the injury can be measured by the impact it has upon the player’s ability to perform. This would include the time it takes to return to the field. It appears from the aforementioned study that the tissue basis for the injury does not explain the extent of the lay-off. What other factors could play a role?
The circumstances around an injury include the state of the tissues and mind in the lead up to the incident. Nothing happens in isolation. There is a background to any injury, even if it is sustained during a tackle, sprint or other seemingly unique event. The background includes general fitness, tissue health, stress, emotional state, hydration, fatigue and a previous experience of injury, particularly if it is in the same body region.
A new or recurring injury – what to do?
Therefore, when assessing a new injury, pain or recurrence, it is vital to consider these factors to establish early on the potential risks for longevity of the condition. A rapid diagnosis, reassurance and a plan certainly help. The player needs to know what has happened, what can be done and what they will need to do to get back to the field of play. This is the same for any level of participation. The immediate way in which the inury is managed and thought about by the player can have an impact upon the recovery. For example, if the injury is ridden with fear and concern, often unhelpful choices are made with regards to self-treatment. Knowledge allows for adjustment and effective management to move forwards through the healing process proactively towards the more functional stages of recovery without unneccesary anxiety.
Pain without an obvious injury or damage
Pain can often exists without any significant damage to the tissues, or any at all in some cases. A problem can present as a hamstring pull, it feels like a hamstring pull, yet there is no sign of an actual injury. Equally, a player could rupture muscle fibres and not feel the pain immediately. In most cases the pain is largely co-existent with the injury, but as we have seen, there does not have to be a huge tear. The message is that we should not use pain as the sole guide to the severity of the injury, however we must seek to treat the pain in the best way we can to reduce the risk of pathological behaviours developing-that would prolong revovery. In a less acute situation when there are no clear signs of injury, often there is sensitivity to movement in the sciatic nerve that has become excited through the mechanism or irritated by inflammatory molecules. This can be highlighted with the slump test. The sciatic nerve supplies the hamstring muscles and when sensitive can manifest pain in any of the tissues in which it innervates.
The seriousness of an injury is very individual with a hamstring injury potentially affecting the career and income of the professional player versus the inconvenience and disappointment of an amateur, part-time player, although with no-less suffering. How much damage has been sustained will also vary and cannot be assessed purely on the basis of the amount of pain. Many factors influence how an individual responds and copes with an injury, and certainly fortifying these mechanisms is key in the early stages with rapid diagnosis, reassurance and treatment.