Screening the lumbopelvic muscles for a relationship to injury of the quadriceps, hamstrings, and adductor muscles among elite Australian football league players.
Hides JA, Brown CT, Penfold L, & Stanton WR (2011). The Journal of Orthopaedic and Sports Physical Therapy, 41 (10), 767-75 PMID: 21891873
https://www.ncbi.nlm.nih.gov/pubmed/21891873
The transition from
offseason to preseason training for many sports carries a substantial risk of
thigh muscle strain injury (quadriceps, hamstrings, and adductors). Due to the contribution of the lumbopelvic
region (core stability) to lower extremity function it is thought that the size
and asymmetry of lumbopelvic stabilizers may play a role in these injuries. To assess
this theory, Hides et al assessed the relationships between thigh muscle strain
and lumbopelvic muscle (i.e., psoas major, quadratus lumborum, and multifidus
muscles) size and asymmetry as well as transverse abdominis ability to contract
and draw in the abdominal wall. Prior to
the preseason training period 34 elite Australian football players had the
cross-sectional area of each lumbopelvic muscle quantified with magnetic
resonance imaging (47 players were initially screened but 13 were lost to
follow-up). At the end of the 3 to 4
month training season 12 thigh muscle strains occurred: 2 hamstring strains, 4 quadriceps
strains, and 6 adductor strains.
Severity was determined by number of days lost of activity: 23 no
injuries (0 days lost), 5 mild injuries (1 to 3 days lost), and 6 severe injuries
(greater than 4 days lost). Mean cross-sectional
areas of the multifidus muscles were significantly smaller among athletes with
a severe thigh muscle strain compared to athletes with no injuries. Muscle size or asymmetry of the psoas major or
quadratus lumborum, as well as ability to contract the transverse abdominis were
not related to thigh muscle strain occurrence or asymmetry. Multifidus mean cross sectional area at L5 spinal
level predicted severe thigh muscle strain with 96.4% specificity (correctly
predicting a player not getting a severe strain) and 83.3% sensitivity (correctly
predicting a severe strain).
offseason to preseason training for many sports carries a substantial risk of
thigh muscle strain injury (quadriceps, hamstrings, and adductors). Due to the contribution of the lumbopelvic
region (core stability) to lower extremity function it is thought that the size
and asymmetry of lumbopelvic stabilizers may play a role in these injuries. To assess
this theory, Hides et al assessed the relationships between thigh muscle strain
and lumbopelvic muscle (i.e., psoas major, quadratus lumborum, and multifidus
muscles) size and asymmetry as well as transverse abdominis ability to contract
and draw in the abdominal wall. Prior to
the preseason training period 34 elite Australian football players had the
cross-sectional area of each lumbopelvic muscle quantified with magnetic
resonance imaging (47 players were initially screened but 13 were lost to
follow-up). At the end of the 3 to 4
month training season 12 thigh muscle strains occurred: 2 hamstring strains, 4 quadriceps
strains, and 6 adductor strains.
Severity was determined by number of days lost of activity: 23 no
injuries (0 days lost), 5 mild injuries (1 to 3 days lost), and 6 severe injuries
(greater than 4 days lost). Mean cross-sectional
areas of the multifidus muscles were significantly smaller among athletes with
a severe thigh muscle strain compared to athletes with no injuries. Muscle size or asymmetry of the psoas major or
quadratus lumborum, as well as ability to contract the transverse abdominis were
not related to thigh muscle strain occurrence or asymmetry. Multifidus mean cross sectional area at L5 spinal
level predicted severe thigh muscle strain with 96.4% specificity (correctly
predicting a player not getting a severe strain) and 83.3% sensitivity (correctly
predicting a severe strain).
This study provides
further evidence that local stabilizing muscles of the lumbar spine may play a
role in lower extremity injury. The
multifidi are important stabilizers, sense lumbar spine position (because they
are dense with muscle spindles), and hold lordosis; all of which has implications
for pelvic position and thus functional implications for the musculature that
attaches on the pelvis (e.g., quadriceps and hamstring). The lack of
association between thigh muscle strains and the psoas major, transverse
abdominis, and quadratus lumborum is thought to be due to several possible
factors: 1) these muscles are less involved in lumbopelvic stability compared
to the multifidus, 2) the ability to draw in the abdominal wall may not be
relevant among elite athletes that can perform the task well, and 3) low sample
size. The addition of measuring the
multifidus cross-sectional area to current injury screening tools (physical
exam, functional movement screening, landing kinematics) maybe a worthwhile
venture for assessing injury risk. Ultrasound imaging could be an efficient
method to do these measures since it is
validated and maybe more accessible and cost effective to
clinicians. This would allow us to
target the often time consuming and clinician intensive interventions to
improve multifidus activation to those with deficits (ultrasound imaging may
even have a role as a biofeedback tool). Has anyone incorporated core training
(or more specifically multifidus activation exercises) into their injury
prevention programs? If so, what are your experiences with these interventions?
further evidence that local stabilizing muscles of the lumbar spine may play a
role in lower extremity injury. The
multifidi are important stabilizers, sense lumbar spine position (because they
are dense with muscle spindles), and hold lordosis; all of which has implications
for pelvic position and thus functional implications for the musculature that
attaches on the pelvis (e.g., quadriceps and hamstring). The lack of
association between thigh muscle strains and the psoas major, transverse
abdominis, and quadratus lumborum is thought to be due to several possible
factors: 1) these muscles are less involved in lumbopelvic stability compared
to the multifidus, 2) the ability to draw in the abdominal wall may not be
relevant among elite athletes that can perform the task well, and 3) low sample
size. The addition of measuring the
multifidus cross-sectional area to current injury screening tools (physical
exam, functional movement screening, landing kinematics) maybe a worthwhile
venture for assessing injury risk. Ultrasound imaging could be an efficient
method to do these measures since it is
validated and maybe more accessible and cost effective to
clinicians. This would allow us to
target the often time consuming and clinician intensive interventions to
improve multifidus activation to those with deficits (ultrasound imaging may
even have a role as a biofeedback tool). Has anyone incorporated core training
(or more specifically multifidus activation exercises) into their injury
prevention programs? If so, what are your experiences with these interventions?
Written by: Dustin
Grooms
Grooms
Reviewed by: Jeffrey
Driban, Jimmy Onate
Driban, Jimmy Onate
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I am glad this topic is getting more attention. While I think hamstring strains arise from a multitude of issues which are both person and sport specific, lumbopelvic dysfunction and weakness is a factor that is modifiable and can be addressed in a prevention program. Over the past six months I have been incorporating a hamstring rehab protocol proposed by Sherry and Best (A comparison of 2 rehabilitation programs in the treatment of acute hamstring strains, J Orthop Sports Phys Ther, March 2004) in both acute and chronic hamstring cases. The program consists of progressive agility and trunk stability (PATS), and so far I have had good results with return to play, decreases reinjury and severity of injury when it does reoccur. In Sherry and Best’s study comparing the PATS program to a traditional strength/stretch program, the PATS program had a quicker return to play (22.2±8.3 days of PATS vs 37.4±27.6 days for strength/stretch) and a lower recurrence of injury in a one-year period (7.7% for PATS vs 70% for strength/stretch).
I think the combination lumbopelvic strength and coordination, eccentric hamstring strength, and the challenge it provides to the athlete (which keeps them engaged), makes the program successful in clinical practice. Although hamstring injuries are complex and multifaceted, core strength is one area that is easily improved and has benefits that extend beyond prevention and rehabilitation of the hamstrings.
Thanks for the comment Natalie!
You bring up a great point and the Sherry study is a good example of a rehabilitation program that can easily be modified to be incorporated as an injury prevention intervetnion. I know with my track and soccer athletes I have had much better outcomes with the PATS program for rehabilitation, it was a hard sell at first to convince some coaches that not targetting the damaged muscle but the proximal(specifically pelvic) stabilziing muscualture may yeild faster RTP and decrease recurrence but with careful explaination(improved pelvic control, mitigating central adaptations post injury, actually resting the damaged tissue) and evidence based results are hard to argue with.
Also I have used the 11+ developed by FIFA's medical team in the soccer kids to great results, incorporating both proximal stability adn eccentric hamstirng. Check it out below
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2600961/
I am interested in looking at both of these programs. The only problem is I don't have a membersip to any research databases and the PMC number provided only has an abstract. Any other places I can find these or can any one email me a copy some how?
Also, I am curious as to where and how you came across these programs.
Thanks!
Jake Marshall ATC
Hi Jake:
Thanks for the comment. Which programs are you referring to? The study in this post did not have an intervention. It was focused on assessing whether lumbopelvic muscles were associated with injuries during preseason.
If you are interested in the program that Dustin referenced in his last comment then the link at the bottom will take you to the free full text.
Thanks!
While I agree with the importance of the problem with this study, I have concerns over the potential clinical applications. The use of MRI, while informative, is not a cost-effective model to test for cross sectional area of the multifidus in athletes. Professional athletics may be able to conduct this type of testing, but this method is not affordable to the generalized population. I believe that non-elite athletes would also possess other potential risk factors (i.e. muscular weakness, imbalances, or skill task level) besides the multifidus CSA that would probably be factors with hip, groin, or thigh injuries. These factors could be addressed through clinical assessment, training, or rehabilitation in non-elite athletes to reduce injuries. I agree that the multifidus CSA could be a potential risk factor, but until a more economical diagnostic procedure or clinically relevant way to test this becomes available, I would refrain from having every athlete tested based on this study.
An interesting point made in this article is the classification of injury. The goal of this study was to examine the relationship of preseason injuries in elite AFL players, with a total number of training sessions of 26 over four months. The classifications of severity of injuries were defined as no injury with no time missed, 1-3 training session missed, and over 4 training sessions missed. This was concluded based on equal size groups for injury resulting in missed training. However, severe injuries resulted in a range of 4 up to 17 total sessions missed.
The authors mention the use of ultrasound imaging instead of MRI to reduce costs and increase measurement frequency. I believe that this can be used to effectively study other athletic populations or previously injured athletes and obtain valuable information. I would also be curious how athletes with previous injuries compare to those without a history of injury in the area of identifying potential risk factors for re-injury.
Jeff,
The programs I was referring to where the ones mentioned in the comments not the study. Natalie mentions " Over the past six months I have been incorporating a hamstring rehab protocol proposed by Sherry and Best (A comparison of 2 rehabilitation programs in the treatment of acute hamstring strains, J Orthop Sports Phys Ther, March 2004) in both acute and chronic hamstring cases." I am asking some people I know if they have that particular publication but I have had no luck in the one day I have had to look and I am still rather new to the field so my "network" is not yet that big and my knowledge of where to look for these things is still rather limited.
The other program mentioned is the PATS program Dustin mentioned. I will check out the link you provided and I thank you for providing it.
Lastly, Mark makes a very good point and one I think research has been been either hesitant to address or has addressed and has not received the attention it deserves. Many studies use methods of evaluation that is beyond the reach of many of us. These studies are a good start but more needs to be done on how the same testing results can be achieved by those of us who do not have access to these types of technology and resources. But of course there will always be more questions then there are answers.
I would also like to thank the writes and reviewers of these articles for making these articles understandable to myself and others who do not have doctorates in research. I often find myself frustrated when trying to decipher these studies mainly due to the language that is often used. I do my best but often times the way study articles are written is beyond my capabilities to understand let alone put into effect. Some times I feel like they are written in another language.
Hi Jake:
I am not sure why, but A comparison of 2 rehabilitation programs in the treatment of acute hamstring strains, J Orthop Sports Phys Ther, March 2004 is available at…
https://www.thiagovilelalemos.com.br/downloads/esportiva/A%20Comparison%20of%202%20Rehabilitation%20Programs%20in%20the%20Treatment%20of%20Acute%20Hamstring%20Strains.pdf
Welcome to the field and the network 🙂
Yes, research sometimes uses techniques that are not commonly available to clinicians but the data can lead in a few directions:
1. The data could inspire new interventions or screening tools that don't require the complex measures. For example, if a lack of lumbar stabilization is an important predictor of lower extremity injuries then perhaps we can focus on lumbar stabilization exercises in our pre-season/off-season training programs.
2. As Dustin pointed out in the post: Yes MRI is expensive but perhaps we could perform similar assessments with ultrasound which is cheaper and more readily available in clinics.
There's plenty of other ways that studies with more complex instruments or measures can alter our clinical practice today. Sometimes even basic science work can influence how we do things in the clinic.
You bring up some good questions as well related to how athletes with previous injuries compare to those without a history of injury in the area of identifying potential risk factors for re-injury. I'll leave that one to Dustin 🙂
Thanks again for the comment and keep them coming.
I'm glad that this study was posted because i have been having some good conversations regarding lumbopelvic control. Here are a couple of items that i've really begun to consider when dealing with a hamstring strain.
First is the low back posture, i'm not certain that i agree witht the statement that abdominal drawing in might not be part of the solution. While this study dealt with elite athletes, most of us aren't. BTW, I've seen some pretty darn high level athletes with poor lumbar posture. If the patient has a S posture, increased lumbar lordosis, that's a red flag. I feel that we should begin analyzing passive hamstring length in 2 fashions and I'd call them functional length vs true length. First, look at it like we always do, supine with knee extended and taking them into passive hip flexion. Reset the patient, and then have them perform a posterior pelvic tilt, hold it, and then perform the passive SLR. I have done this on a few people over the past 2 weeks and the difference between the ROM is very noticeable.
As far as cost effectiveness goes, how about this for an idea? Earlier i posted a write-up about LP control in baseball players utilizing a device called the level belt. Would it be feasible to determine the amount of LP control by using said device, and performing a functional task, as well as using a blood pressure cuff under the lumbar spine to get the pressure reading needed to get a patient into LP neutral? Or have them do a leg lowering test with the blood pressure cuff and get a reading when LP neutral is compromised. Maybe you could correlate between the pressure and the belt readings… Maybe big wigs like Steve and Jeff could use their fancy IR markers and analyze pelvic landmarks pre and post intervention to determine how far they move and what effect pelvic alignment has on hamstring length/ROM all the while incorporating zero stretching. I'm just tossing ideas around.
With the way that our posture is compromised everyday(SITTING!!!!!!) it's easy for us to get stuck in that lower crossed syndrome (weak abs and glutes, strong/tight hip flexors and erector spinae) putting our lumbar spine basically in an extended position 24/7 and crushing the multifidi. All that said, there has to be more to it than just saying "he pulled a hammy/quad/groin"
"What happened? I just blacked out…." Frank the Tank
Thanks for the comments Mark, Jeff and Jake. It is great that this website is making a difference for clinicians and sparking discussion!
Thanks to Jeff for posting the websites, if you are still having trouble I have no problem e-mailing the PDFs. There are a few British journal of sports medicine articles concerning the 11 as well. Check this website for the program.
https://f-marc.com/11plus/
It looks like Jeff took care of the Sherry article.
Ultrasound assessment is more popular in other countries as a biofeedback tool for physiotherapist and it seems to be becoming more common in the US, but you are correct right now there are limited methods to assess deep core muscle function. We do need more clinician friendly methods to assess injury risk. Which gets to Mark’s point that injury risk is a multifaceted phenomenon and isolating one muscle’s cross sectional area ignores many other factors that may influence injury risk to a greater degree. Myer and Hewett just recently published a risk factor analysis for ACL injury designed to correlate clinical tools with laboratory tools.
Strength & Conditioning Journal:
June 2011 – Volume 33 – Issue 3 – pp 21-35
doi: 10.1519/SSC.0b013e318213afa8
Article
Real-Time Assessment and Neuromuscular Training Feedback Techniques to Prevent Anterior Cruciate Ligament Injury in Female Athletes
Myer, Gregory D PhD, CSCS1,2,3,4; Brent, Jensen L CSCS1; Ford, Kevin R PhD, FACSM1,2; Hewett, Timothy E PhD, FACSM1,2,4
And in our lab here at OSU we are working with high schools in the area to implement a clinical based injury screen taking 10 minutes and easy to use clinical tools. So stay tuned to see this one put out!
On the note that perhaps everyone could benefit from intervention, that is a very possible solution. Kiesel did a study using ultrasound and the treatment based classification system for low back pain and found that if you fit stabilization you had lower muscle activation, so using clinical predictor rules like that may limit our need for fancy machines.
On the note about previous history of injuries, since this was prospective that helps show the injury did not cause the atrophy but the atrophy happened prior to injury. However the study did not go into much detail regarding this issue beyond stating that the muscle cross sectional areas were not related to whether a previous injury existed… I have to wonder if they documented or had good access to quality records though… Hard to say but based on their results and other literature it is safe to at least consider the multifidus being related to injury.
Mark
That is awesome that you reviewed a one of Ajit and Mckenzye's level belt papers! I need to find your SMR post! Those two are actually part of the lab I work in at Ohio State. They actually already did a correlaton study with the pressure biofeedback unit and a leg lowering task to determine its validity to assess pelvic position. I will find that link and post it.
Perhaps we should ask them to send you a level belt and do some joint research 🙂 The project I alluded too in my previous post is collecting some level belt data as well.
Validation of a New Instument for Measuring Trunk Stability in Standing: 734: May 31 1:30 PM 1:45 PM
McKenzie, Christopher S.; Mc Arthur, Nathan R.; Pedroza, Angela; Best, Thomas M. FACSM
Author Information
The Ohio State University Medical Center, Columbus, OH.
Email: Christopher.McKenzie@osumc.edu
PURPOSE: Documentation to measure trunk strength stability in a functional upright position does not exist in the literature and requires validation for utilization in future research. The objective of this study was to develop and validate a trunk stability measuring tool which could be used with baseball pitchers during their transition from two legs to a single leg pitching stance.
METHODS: 51 healthy baseball pitchers (18–48 years of age) performed a straight leg raise test while lying supine over a partially deflated blood pressure cuff. The subjects performed lower extremity leg raises as described by Gilleard (1) to determine their level of abdominal muscle activity. The subjects also were tested using the Level Belt apparatus. With the Level Belt apparatus applied to their waist, the subjects attempted to transition from two legs to a single leg pitching stance and balance while maintaining a neutral trunk position. Subjects were graded based on their ability to progress through the maneuver. Scores ranged from 1, for those unable to maintain a level pelvis, to a score of 4, for those who were able to maintain a level pelvis and balance for over 5 seconds.
RESULTS: The Level Belt test showed a significant correlation to the Gilleard test (p<0.001) using a spearman's rank correlation. (r = 0.54). Subjects were more likely to score higher on the Gilleard test than the Level Belt test. (Wilcoxon signed rank test, z=-3.168, p<0.002)
CONCLUSIONS: Trunk stability data obtained using the Level Belt is repeatable while performing a new single leg stance test. The Level Belt is positively correlated to the Gilleard test, as the scores rise on one test, they rise on the other. However, subjects are more likely to have a higher score on the Level Belt test compared to the Gilleard test. This could be attributed to the exponential increase in difficulty in the Gilleard test_the straight leg raise with two legs is much more difficult than the unsupported level before it. Thus, use of the Level Belt should allow for future trunk stability research to be performed in a functional standing position.
1. Gilleard WL, Brown JMM. Anelectromyographic validation of an abdominal muscle test. Arch Phys Med Rehabil. 1994;75:1002–7. Bibliographic Links
I was glad to see this article posted as it deals with many of the injuries that I deal with. The article mentions that the transverse abdominus may not have as big of a role as it is thought to have. I disagree with this statement and don't believe the article gives sufficient evidence to prove that it doesn't (sample size etc). The transverse abdominus activates as people go to move whether it be to kick a ball or swing a bat. The TrA generally contracts, but someone with predisposing back pain will have a delay in the activation of their TrA. With athletes that I am working with that have thigh injuries etc, they tend to have a weaker core and they lack flexibility in their hip flexors, gluts, and hamstrings.
As far as good exercises, the transverse abdominus and the multifidus (when getting into more functional exercises for rehab) are not stand alone muscles to strengthen. That being said, if an athlete can learn to do an abdominal drawing-in manuever and pelvic flooring and have that become second nature, I believe that it will aid in strengthening their overall core that has been talked about as helping prevent thigh muscle strains.
As for imaging, ultrasound is definitely a good way to measure. It does, however, take practice to be able to identify the right muscles and the correct way to measure them.
I think your right Shandi and their study did downplay the transverse abdominus. Since they only looked at the corset effect during an abdominal hollow (just displacement of the abdominal wall) and not its activation pattern as you allude to is a limiting factor. The work by Paul Hodges regarding its activation sequence(before limb movement in healthy, after in LBP) is a key component of this muscles function and just inducing voluntary contraction may not be the correct way to assess it and relate back to function.
Great comments all!
That's an amazingly useful discussion..