On Richard Hill's hamstring

Friday November 07 2003

Nigel Roe

ProSport is the Number One range of sports support in the UK - helping people relieve, prevent and protect them from the risk of high-impact and potential injuries.

This week, in his exclusive column for ProSport and Planet Rugby, Saracens physiotherapist Nigel Roe (pictured) writes about Richard Hill's hamstring injury - looking into the mysteries surrounding hamstring problems and when it is a 'tear' or just a 'strain'.

It's been three weeks and four days since Richard Hill picked up a hamstring injury in the 50th minute of England's opening game against Georgia. The England and Saracens back row stalwart has been out of the World Cup action since and has missed yet another starting line-up for this weekends quarter-final clash with Wales. This we all know. What isn't so clear is why there is so much confusion about the time-frame for Hilly's return.

Shouldn't he be back by now?

For me it's a straight-forward "No" to this question. I think it's fairly obvious what's going on & let me share with you some insight from a team management and medical perspective.

Fact one is that there is confusion about how much damage Hill has actually done to his hamstring. There are two reasons for this.

The first is the natural response of a management team in downplaying the severity of a key players injury. You don't want your opponents to know that a  certain player won't feature, or give them a chance to exploit this knowledge too far out from a game. It throws an opposition if they have to change tactics for a late withdrawal. Little things like this count in such big games.

The media itself perhaps generates the second. I have seen online and newspaper reports of the same Clive Woodward interview last week, 17 days after Hilly's injury, with many different journalistic "interpretations of what was said in the same interview".

Some journalists' quote Clive as saying "hamstring twinge" while others say "tear" including the report on the RFU site (which I guess we can assume is accurate). Or perhaps Woodward is using different terminology at different times. It's hard to know for sure whether it's Clive or the reporters who are guilty of confusing the terminology. "Surely 'a twinge' and 'a tear' aren't that different?" you may ask. Well they're about the same as an Englishman and a Frenchman, (or a Kiwi and an Aussie if you're southern hemisphere inclined). That should put it in perspective, but allow me to elaborate.

A twinge in medical reference is generally interpreted as a protective tightening or spasm of just a small band within the muscle. There is no actual gross tissue damage in terms of muscle fibre tearing. A tear is a different matter all together, and involves actual physical disruption of muscle fibres. As mentioned in my column on Kyran Bracken and Matt Dawson, muscle injuries are graded medically into three grades: a Grade One is a strain with no or absolutely minimal muscle fibre disruption (The 'twinge' scenario): a Grade Two is a partial tear of a muscle belly: a Grade Three is a complete tear.

Grade One is one-two weeks recovery, Grade Two is two-four weeks recovery (more like six with a hamstring because of it's complex role: see below); Grade Three is usually four-six weeks plus. Recovery time is influenced by the site of the injury. A tear within the muscle belly generally heals faster than a tear between the muscle/tendon junction.

With a tear, there is usually bleeding and swelling within the muscle, and a 'weak point' where scar tissue forms to bridge and 'glue' the gap in the muscle where the tear has occurred. This healing area not only has to rejoin the damaged muscle fibre ends, it has to have time to 'toughen up' and adapt to the loads being put through it. As you can imagine, these loads are fairly extreme in a top-level athlete, and the job of a hamstring is a very complex one indeed. It is a special muscle in that it crosses over not the usual one, but two major joints, the hip and the knee, and has a big role in controlling movement at both.

For those of you with a technical interest, have a glimpse at its job description during a single stride in running. The rest of you skip down past the bullets &

* Decelerate hip flexion during swing phase
* Knee extension while accelerating hip extension
* Decelerate hip flexion at foot strike
* Decelerate lower leg internal rotation at mid-stance
* Accelerate hip extension and external rotation prior to foot strike
* Accelerate external rotation of the lower leg before foot strike and during push-off
* Provide sacroiliac stabilisation via deep longitudinal system after heel strike

Hopefully that helps to make clear that a hamstring tear is a complex beast. But how do you diagnose what type of injury it is? The amount of stretch before pain, and the amount of pain on contraction of the hamstring are the initial indicators. But just to confuse matters, a strain can initially be just as painful as a tear, and some small tears are not that painful at all, so pain is not a good early indicator of severity. Ultrasound scanning (as for pregnancy) is perhaps the easiest way to accurately see how much damage has been done.

So next time you hear someone tell you how they came back from there hamstring tear in a couple of days or a week, you know that they in actual fact they had a grade one injury/strain/'tweak'. They're not the hero they make out to be. If the muscle is torn it's torn, and no magic cure will change that. A twinge though and you're back in days not weeks.
 
Which brings us to fact two. Richard Hill has a hamstring tear (confirmed by Clive on the RFU site) that is fairly obviously a Grade Two injury, and which is still inside its normal healing and rehab timeframe. By "normal", I mean the accelerated environment of a professional rugby team medical set-up with multiple treatments each day and cutting edge rehab.

Some Grade Two's take beyond the four to the six-week mark as mentioned, depending on location and size of the tear. Bottom line: No need to panic English supporters. It's just a matter of how much leeway Clive is prepared to give in terms of time beyond this weekend's game. Obviously with a player of Hilly's calibre, you give him as long as you possibly can, but the line will have to be drawn at some point. Zinzan Brooke goes as far to say that England will not win the World Cup without him. By this time next week we will probably know if Clive agrees.

Cheers
Nigel

Footnote: Spoke to Hilly this week in Brisbane where he was catching up with old team-mate Tim Horan. He was in good spirits but I'm under pain of death to repeat any comment he had to make on his hammy! You will just have to wait and see ...

Click here to view a table on all the RWC injuries!

ProSport is available at all good UK pharmacies.