ACUTE HAMSTRING INJURIES IN RUGBY PLAYERS: THE INFLUENCE OF POSITIONING DURING ICE THERAPY ON MUSCLE LENGTH Becker, D Rayner, L van Zyl, E Walters, C P Malherbe* SUMMARY The effect on muscle length of positioning with ice appli­ cation to acute hamstring Injuries in rugby players was examined. Ice was applied with the hamstring muscle group in either the lengthened or the shortened position. Players with grade I or II hamstring injuries were ran­ domly allocated (via the randomized block method) to the different treatment methods. The active hamstring length of the injured leg was measured by means of knee extension before and after treatment on days 1, 2 and 3 post-injury. The uninjured leg was measured on days 1 and 3. The discussion of results covered only the clinical obser­ vations since the experimental group was too small for statistical analysis. OPSOMMING Die invloed van posisionering tydens ysbehandeling van die akute hamstringbesering is by rugbyspelers ondersoek. Ys is met hamstringe in die verkorte of in die vertengde posisie toegedien. Spelers met graad I of II hamstringbeserings is vol- gens die ewekansige blokmetode aan die verskillende behandelingsmetodes toegewys. Ak- tiewe hamstringlengte van die beseerde been is voor en na behandeling deur middel van knie- ekstensie gemeet op dag 1,2 en 3 na besering. Die gesonde been se metings is op dag 1 en 3 geneem. Die bespreking van resultate is slegs na aanleiding van kliniese waarnemings gedoen, aangesien die steekproef te klein was vir statistiese ontleding. INTRODUCTION Clinical work at the Student Health Service in Stellen­ bosch as well as regular contact with the service made the authors aware during 1988 of the high incidence of muscle rupture, particularly hamstrings, amongst rugby players and athletes. Complete rehabilitation after a hamstring rupture, i.e. until all the accepted criteria for return to sport1 have been met, can be lengthy ( 3 - 9 weeks)2, and is thus accompanied by considerable loss of playing time. Injured players therefore tend to return to the sportsfield before complete recovery has taken place. Recurrent injury is consequendy not simply a high risk but a fact. The authors realised that really effective treatment was necessary to keep rehabilitation as short as possible. It also appeared that regaining complete suppleness (muscle length), especially of the injured leg (one of the criteria for return to sport), was a problem for the physiotherapist in the sports clinic as far as the hamstrings were concerned. The authors therefore began questioning the practice of keeping the torn muscle in its relaxed, shortened position during ice therapy in the acute phase. An hypothesis was posed that positioning which lengthened the muscle in the early stages during ice therapy would facilitate the retention and/or improvement of hamstring length and thereby shorten rehabilitation. LITERATURE REVIEW Immediately after muscle rupture bleeding appears and an inflammatory reaction develops. The “RICE” regime3,4’5 (rest, ice, compression and elevation) limits these and is essential to the creation of optimal conditions for muscle recovery through the laying down of collagen6. However, specific recommendations were found in the literature for the use of positioning which lengthened the muscle. Gray and Wilkerson4, and Evans6 maintain that col­ lagen is laid down in a more orderly fashion and the formed fibrous junction is stronger if the muscle is lengthened rather than when there is loss of normal tension on the damaged tissue. Capable of changing the frequency from 1 Hz to 5000 Hz. > Tip-touch sensor system for activating the laser beam. i Measurement of the infra-red radiation using an optical sensor. »Time clock which works only when the laser beam is activated. > Safety glasses designed for laser therapy, consisting of interference filters. These keep the visual spectrum at 95% of normal. »Unit built to comply with the international safety regulations IEC 601. MEDICAL DISTRIBUTORS (EDMS) BPK (011) 29-6931 (031) 37-1501 REG. NO. 57/01868/07 Bladsy 12 (021) 47-4440 (012) 346-1279 Fisioterapie, Augustus 1990, dee146 no 3 R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) Another aspect that came to light was the influence of ice on collagen formation (the plastic and elastic properties of collagen). According to Marino8 cooling after the muscle has been placed in stretch increases the plastic flexibility of collagen. The collagen fibres therefore lengthen. This gives further support to the use of positioning that lengthens the muscle, but will apply only from day 4 or 5, after the collagen has been laid down. METHOD Research question Against this background the following question was posed: Is the improvement in hamstring length on day 2 after rupture greater after ice application with the muscle in a lengthened position than in the traditional shortened posi­ tion? Study structure The investigation was carried out as a random clinical study of residence league rugby players at the University of Stellenbosch. They had suffered grade I or II hamstring rup­ ture (in any par t of the muscle belly) during games or practices between 11 April and 29 May 1988 and had reported to the emergency clinic within 30 minutes of the injury. An age limit of 18 - 25 years was set. Criteria for exclusion Exclusion criteria included: • club players • grade III and IV hamstring ruptures • previous hamstring injuries suffered since April 1987 • back and leg injuries not yet fully healed • hypersensitivity to ice9 Hamstring ruptures were graded by the student doctor according to a combination of the classification systems of Fox1 and Oakes10. Fox’s classification is subjective and vague in regard to the degree of pain, swelling and muscle spasm but gives usable objective values for the loss of knee extension. The classification of Oakes rests on the history of the injury and gives a clear definition of interference with function as a result of pain, swelling and muscle spasm. The latter offers a more concrete evaluation method. Instrumentation Chemical ice packs 23 x 16 cm from Medac were used for ice application. Their temperature is chemically regulated to remain at 0°C for 20 minutes8, which also limits the danger of freeze burns. Measurement of pain was done by means of a subjective pain scale with 0 = no pain and 10 = severe pain11. Hamstring length was measured by active knee extension of the leg to the point where myoclonus occurred (the active knee extension test - AKET12). The thigh was stabilised in hip flexion during measurement by binding it to a steel rod fixed to the plinth. The pelvis and uninjured leg were secured to prevent pelvic tilt. Measurement in degrees was done with an electronic resistance meter built in between the two arms of a pendulum goniometer and connected to a computer. Changes in tension are registered and converted by an analog-to-number conver­ ter into degrees of movement which are then shown by the computer. Each measurement was taken twice. If the two readings differed by more than 5° the computer automatically rejected them. The average of the two readings was shown. Procedure The injured player came directly from the field and reported to the emergency room. Once the degree of injury had been determined the players were allocated according to the random block Inethod to the two methods of treatment - positioning seated with knee extension compared with prone with knee flexion. Grade II injuries were allocated separately from grade I. The players were followed up for three days: the first night in the emergency room; on days 2 and 3 in the morning at the student health clinic and in the evening at the emer­ gency room. The appropriate positioning and ice application was done on each occasion (4 times). The pain scale was filled in by the player before and after each application of ice. Hamstring length of the injured leg was measured before and after each afternoon’s ice therapy and was later compared with that of the uninjured leg which was measured on days 1 and 3. All measurements were taken by the same researcher. After day 3 the players were referred for follow-up treatment. The ice packs were applied for 20 minutes on the most painful area. Compression was applied by binding the pack with a crepe bandage. Elevation was not possible with the standard positionings. The positioning for treatment method A stretched the hamstrings in the sitting position over the hip as well as the knee. The heel was placed on a 7 cm block to ensure knee extension and combined with maximum hip flexion by means of adjusting the head of the plinth within the limits imposed by pain. The position for treatment method B was prone with knee flexion; thus the hamstrings were shortened and relaxed over the hip and knee. “Basketweave” bandages were applied after treatment for grade II injuries. No crutches were supplied. The following written instructions were given to each player: • If pain is experienced ONLY Panado may be taken (no anti-inflammatory drugs). No medication could be taken after 12 noon on days 2 and 3. • No sporting activities such as jogging or bicycle riding were allowed for 48 hours after injury. • No preparations, e.g. Deep Heat, Wintergreen, Reparil Gel or Heat Rub could be applied to the injured area. • No other home treatment could be used. RESULTS Of a total of 9 hamstring injuries suffered during the set period only 5 players complied with the criteria : 1 wing, 2 fullbacks and 2 centres. Four grade I and one grade II injuries were seen. The first and last measurements (day 1 and day 3) of the Physiotherapy, August 1990, vol 46 no 3 Page 13 R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) Individual FIG 1. First and final measurements (day 1 & day 3) of hamstring length: control leg (O) versus injured leg (A) injured and control leg of the different individuals are shown in figure 1. Figure 2 represents the changes in hamstring length of the injured leg, in degrees, before and after treatment over the three days. DAY 1 DAY 2 DAY 3 FIG 2. Hamstring length of the injured leg before and after treatment over three days The pain scale data showed a definite reduction in pain after each treatment and a progressive diminution of pain over the three days in all five players. DISCUSSION The unsatisfactory experimental group did not allow of statistical analysis. Discussion of the results is therefore based solely on the observations of the researchers. From figure 1 it is clear that the readings of the control leg could not be taken as normal for the specific individual and therefore could not be used as a reference point because of the great difference in readings on day 1 and day 3 in two of the four grade I injuries. It was anticipated that measurements of the control leg on day 3 would be lower because the individual was still warmed up and supple on day 1 as a result of the exercise or game. This was noticed only in the grade II injury (figure 1). No warming up was done by the players before measurement on day 3. Readings on day 3 were, however, higher. This could possibly be due to the influence of pain in the injured leg and unfamiliarity with the measurement procedures on day 1. Regarding the measurements of the injured leg: In 3 of the 4 cases with grade I injuries the final reading of the injured leg was lower than that of the control leg (figure 1). This was, however, to be expected because damaged muscle fibres limit muscle length. Tlie grade II injury supports this. The authors expected that measurements after treat­ ment would be higher than before treatment because of the influence of ice and positioning (both shortened and leng­ thened positions) on the muscle length of the damaged muscle. This was clinically substantiated in the grade I injuries as seen in figure 2. Only in 1 out of 12 treatments was no improvement observed. In the case of the grade II injury there was no improve­ ment after one treatment and by the last treatment there was a lessening of muscle length (figure 2). This could be ascribed to the more serious injury with more muscle spasm and pain. Figure 2 shows that both treatments A and B were effective. It was not possible, however, to draw a comparison between the effectivity of the two treatments. The findings of the subjective pain measurements are an indication that both treatments, and therefore both positions, were effective in regard to the subjective diminution of pain. It could not be established which treatment was better. All the injured players were back line players. This confirms the facts from the literature that players who do a lot of pace work have more type II fibres and are more liable to injury13,14. ■ CONCLUSIONS Judged clinically both treatments A and B were gener­ ally effective in regard to the reduction in pain and the improvement of hamstring muscle length during individual treatments from day 1 to day 3. It appears from the loss of muscle length after day 3 in the grade II injury that conventional “RICE” treatment alone is not sufficient in the case of acute grade II injuries. The possibility exists that anti-inflammatory drugs will encourage more rapid recovery of muscle length in this case. The research question could not be answered by testing the hypothesis because statistical procedures could not be used for the very small experimental group. This study can, however, be seen as preliminary to further research in this connection. No practical problems were encountered in car­ rying out the general or specific procedures. The difference in the measurements of the healthy leg need not handicap the study. The authors have proved that the study is practically feasible. It is strongly recommended that, for the sake of statistical significance, the study be continued to collect more data. The study should, however, be carried out over a longer period and/or more sports such as soccer and hockey should be included to assemble an adequate test group. It is recommended that if the project is followed up, measurements should also be taken after three weeks. This would enable it to be established whether the treatment in the acute phase had a lasting influence on muscle recovery. Bladsy 14 Fisioterapie, Augustus 1990, deel 46 no 3 R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) MedSolve ... Now incorporating New Dispensing Module! During the 1980's, MedSolve revolutionised practice management. FACT: Practice management in the '80’s demanded quick, successful solutions. MedSolve gave you just that and revolutionised day-to-day operations control and now have over 1500 installations to illustrate its success. But the '90's will present new challenges and new frontiers. Existing first generation practice management systems will simply be unable to cope. THE GOAL: To develop a comprehensive medical practice management system that will take you into the 1990’s and well beyond. THE NORIDATA ACHIEVEMENT: The NEW MedSolve from Noridata. Your 2nd generation practice m anagement system. 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Will you or your nearest dealer please contact me with more information on NEW MedSolve NAME____________________________ MedSolve South Africa's most successful practice management system NORIDATA DIVISION OF NORISTAN LIMITED ADDRESS_ TEL CODE_ JOHANNESBURG BRANCH PO BOX 31469 BRAAMFONTEIN 2017 TEL (011) 484-4380 CAPE TOWN BRANCH HOWARD STUDIO HOWARD PLACE PINELANDS 7405 TEL (021) 531-0944 Physiotherapy, August 1990, vol 46 no 3 Page 15 SAL 1265/A4D R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) Control Physiotherapists HEAD OFFICE, CAPE TOWN The minimum commencing salary is R38 697 per annum but will be adjusted according to experience. The successful candidate has to be registered as a Physiotherapist with the S.A. Medical and Dental Council. A qualification and/or experience in management will be a recommendation. The names and addresses of three re­ ferees must be furnished. Duties: Advising management and co-ordinating the overall func­ tioning of Physiotherapy Services in the Cape Province. Please send your application on the prescribed form (Z.83 obtainable from any government office) to the Executive Director, Hospital and Health Services, P.O. Box 2060, Cape Town, 8000. Closing date: 30 August 1990. LINTAS: 5965 COURSES ON ADULT HEMIPLEGIA : SASP NATIONAL EXECUTIVE COMMITTEE COURSE LEADER ELIA PANTURIN, Israel 1. ASSESSMENT AND TREATMENT : 3 WEEKS DATES: February 1991 VENUE: Johannesburg ± R1000 2. ADVANCED COURSE: ASSESSMENT AND TREATMENT: 1 WEEK DATES: F eb -M ar 1991 VENUE: Cape Town ± R500 APPLICATION FORMS: from The'General Secretary, SASP, P O Box 47238, Parklands 2121. Telephone (011) 643-5934 (mornings) V Physiotherapist PROVINCIAL HOSPITAL, UITENHAGE • Registration with the S.A. Medical and Dental Council as a Physiotherapist is essential. • A salary to a maximum of R29 205 per annum may be granted according to qualifications and experience. Application must be made on the prescribed form (Z.83, obtainable from any government office) and for­ warded to the Medical Superintendent, Provincial Hospital, Private Bag X36, Uitenhage 6230. Closing date: 20 August, 1990. LINTAS : 6198 ERA AGENCY LTD (Medical Services) Coming to the UK? When you arrive please call on us. We have been giving a professional and friendly service placing Physiotherapists throughout the UK for over 20 years. Second Floor, 14/16 Great Portland Street, London W1N 6BL Telephones (071) 636-7414, (071) 637-0507, (071) 580-8915. Physiotherapist KARL BREMER HOSPITAL, KARL BREMER • Registration with the S.A. Medical and Dental Council as a Physiotherapist is essential. • A salary to a maximum of R29 205 per annum may be granted according to qualifications and experience. Application must be made on the prescribed form (Z.83, obtainable from any government office) and for­ warded to the Medical Superintendent, Karl Bremer Hospital, Private Bag X1, Karl Bremer 7531. Closing date: 20 August, 1990. LINTAS REFERENCES 1. Fox JM. Injuries to the thigh. In: Nicholas J and Hershman E, eds. The Lower Extremity and Spine in Sports Medicine. Toronto: The CV Mosby Company, 1986:1987-1117. 2. Reese R. Athletic training techniques and protective equipment. In: Nicholas J and Hershman E, eds. The Lower Extremity and Spine in Sports Medicine. Toronto: The CV Mosby Company, 1986:319-321. 3. Coilek JJ. Cryotherapy: Review of physiological effects and clinical appli­ cation. Cleveland Clinic Quarterly 1985; 52(2): 193-201. 4. Gaiy B and Wilkeison ATC. External compression for controlling trau­ matic oedema. The Physician and Sports Medicine 1985; 13(6): 97-106. 5. McMaster WC. A literary review on ice therapy in injuries. American Journal o f Sports Medicine 1977; 5(3): 124-126. 6. Evans P. The healing process at cellular level: a review. Physiotherapy 1980; 66(8): 256-259. 7. Coole WG and Gieck JH. An analysis of hamstring strains and their rehabilitation. The Journal o f Orthopaedic and Sports Physical Therapy 1987; 9(2): 77-84. 8. Marino M. Principles of therapeutic modalities: implications for sports medicine. In: Nicholas J and Hershman E,eds. The Lower Extremity and Spine in Sports Medicine. Toronto: The CV Mosby Company, 1986: 233-241. 9. Harrison M. Effects of ice treatment. Physiotherapy in Sport 1978; 2(1): 8- 10. 10. Oakes BW. Hamstring muscle injuries. Australian Family Physician 1984; 13(8): 587-591. 11. Elton D, Burrows GD, Stanley GV. A multidimensional approach to the assessment of pain. Australian Journal o f Physiotherapy 1979; 25(1): 33-37. 12. Gajdosik R. Hamstring muscle tightness: reliability of an active knee extension test. Physical Therapy 1983; 63(7): 1085-1090. 13. Garrett WE. Histochemical correlates of hamstring injuries. The Ameri­ can Journal o f Sports Medicine 1986; 12(2): 98-103. 14. Garrett WE. Basic Science of musculotendinous injuries. In: Nicholas J and Hershman E, eds. The Lower Extremity and Spine in Sports Medicine. Toronto: The CV Mosby Company, 1986:42-56. V Bladsy 16 Fisioterapie, Augustus 1990, deel 46 no 3 R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. )