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 Table of Contents  
Year : 2017  |  Volume : 5  |  Issue : 1  |  Page : 71-74

Active release technique in hamstrings strain: Rehabilitation and return to play – a case study

1 Department of Physiotherapy, Gleneagles Global Health City, Chennai, Tamil Nadu, India
2 Department of Physiotherapy, School of Medicine, College of Medicine and Health Sciences, University of Gondar, Gondar, India
3 Department of Physiotherapy, Sree Balaji College of Physiotherapy, Chennai, Tamil Nadu, India
4 Department of Physiotherapy, School of Medicine, College of Health Sciences, and Ayder Comprehensive Specialized Hospital, Mekelle University, Mek'ele, Ethiopia

Date of Web Publication16-Jun-2017

Correspondence Address:
Hariharasudhan Ravichandran
Gleneagles Global Health City, Chennai, Tamil Nadu
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/amhs.amhs_37_17

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Hamstring injuries and its rehabilitation in competitive events such as football targets safe and early return to play. This is because hamstring injuries are more related to prolonged recovery time and high rate of re-injury. In this case study, Zakeer Mundampara, 26-year-old footballer of Chennaiyin FC team (Indian super league tournament), who was rehabilitated for Grade 2 hamstring strain was briefed. To describe the importance of conservative rehabilitation in hamstring injuries and report on player's rehabilitation program and clinical outcome. Zakeer Mundampara was conservatively treated with active release technique for 2 weeks duration. Data collected includes passive knee extension test range of motion and verbal rating score. After 2 weeks of rehabilitation, Zakeer Mundampara had nearly full range of pain-free movement, normal gait and trained to run safely. By the 3rd week, he started to perform all sports specific drills. He was rehabilitated and set fit to play after 4 weeks from the date of injury. Active release technique is effective in hamstring injuries. In this case study, rehabilitation program with an emphasis on active release technique is found to be effective in returning the footballer back to play.

Keywords: Active release technique, cryotherapy, rehabilitation, verbal rating score

How to cite this article:
Ravichandran H, Janakiraman B, Sundaram S, Fisseha B, Yitayeh A. Active release technique in hamstrings strain: Rehabilitation and return to play – a case study. Arch Med Health Sci 2017;5:71-4

How to cite this URL:
Ravichandran H, Janakiraman B, Sundaram S, Fisseha B, Yitayeh A. Active release technique in hamstrings strain: Rehabilitation and return to play – a case study. Arch Med Health Sci [serial online] 2017 [cited 2022 May 19];5:71-4. Available from: https://www.amhsjournal.org/text.asp?2017/5/1/71/208196

  Introduction Top

Hamstrings are the long and powerful group of muscles that span the back of the thigh. The collective term “hamstrings” refers to four muscles (semitendinosus, semimembranosus, long and short head of biceps femoris) located in the posterior compartment of the thigh. In European elite football, hamstring injury is the most common diagnosis: 12% of all injuries are hamstring injuries.[1] Hamstring injuries impair both the player and club performance, as athletes often cannot train and compete for several weeks or even months. Even after return to play athletes have an increased risk of recurrent injury, which has been reported to be 16% within 2 months in football and up to 34% per se ason in Australian football.[2] From an economic point of view, these time-loss injuries have a very negative effect, not only due to their direct cost but also reducing squad availability and likelihood of success. In general, it is believed that hamstring injuries occur primarily during activities or sports that demands extreme speed and power. However, recent studies suggest that hamstring strain or injuries can occur also in slow speed stretching exercises,[3] stretching and kicking movements with large joint excursions.[4] Kicking action is a combination of hip flexion and knee extension resulting in a lengthening of hamstring muscles resulting in injury. Initial treatment of the hamstring typically consists of rest, ice, compression, elevation, and pain relief. However, no optimal treatment regimen has been developed based on carefully designed clinical trials. Currently, the treatment of acute hamstring injuries is predominantly based on several randomized controlled trials that compared different exercise programs.[5] The unique nature of this case study is hamstring strain was rehabilitated with active release technique. The result was significant and satisfactory. Active release technique was developed by P. Michael Leahy. It is a soft tissue mobilization technique that focuses on relieving tissue tension via the removal of fibrosis/adhesions that can develop in tissues from overload and repetitive use.[6] This technique is practiced by chiropractitioners and physiotherapists with an understanding of anatomical structures throughout the body.

  Case Report Top

In this case study, Zakeer Mundampara, 26-year-old male professional soccer midfield player played for Chennaiyin FC, Indian super league tournament 2016, had sustained an injury to his right thigh during the training season. He was examined by the team physician and physio of Chennaiyin FC and the physio part of rehabilitation was briefed out in this case study. During the 12th min of the practice match, Zakeer Mundampara went for a tackle to get the ball from the opponent player and a vigorous kick in the air produced severe pain in his back of thigh. He complained of pain in the right hamstrings.

Physical examination

On field assessment by the physio revealed pain in the hamstrings muscle region with pain intensity of 6/10 in verbal rating core at rest. He was taken out of the field. He had a limping gait with pain intensity of 8/10 in verbal rating score while walking. He was examined. On observation, there is mild redness in proximal thigh, no swelling, no deformity. On palpation, mild warmth and tenderness of Grade 2 was present in the superior musculotendinous junction of hamstrings. Manual muscle testing on the right side was not done to prevent worsening of hamstrings injury if it's a tear. Passive knee extension test was performed. In this test, Zakeer Mundampara was positioned in supine with the hip and knee of the right leg in 90° flexion, while the contralateral leg stays flat on the table. His right knee was extended passively by the physio until reaching the maximal tolerable stretch of the hamstring muscle. The knee angle was measured and it was 50° compared to 90° on the left side. The circumferential measurement was performed midthigh level exactly 15 cm proximal to the superior pole of patella. An average of 3 measurements was taken, and it was 59.8 cm on the left side and 60.1 cm on the right side. Neurological examinations are within normal limits. He was immediately managed with cryotherapy and compression through cryo-cuff machine and Tablet Chymoral forte (to reduce edema). After 6 h, his pain intensity was 4/10 at rest and 6/10 while walking. Magnetic resonance imaging was taken 36 h after the injury (to visualize clear images without edema), which revealed Grade 2 long head of biceps femoris strain at the proximal musculotendinous junction.

Zakeer Mundampara underwent two sessions of active release technique every day by the team physio for 2 weeks. To perform this technique, Zakeer Mundampara was positioned in prone lying with knee flexion. Then the physio applies digital tension along the long head of biceps femoris muscle tissue fibers at tender areas of adhesions. Zakeer is then instructed to actively move the hamstring muscle from shortened position to a lengthened position.[7] Followed by active release technique, kinesio taping was applied along the entire length of long head of biceps femoris. Kinesiotape assists the muscle during contraction, reduces pain and assists in the overall healing of the injured muscle.[8] Posttreatment exercises become a critical part of healing after active release technique has released the restrictive adhesions between the tissues. Posttreatment exercise program planned for Zakeer Mundampara comprised of flexibility, strengthening, proprioception, and cardio workout factors. Stretching of hamstrings within the pain-free range, strengthening of hip musculatures using activation bands above the knee joint and proprioception exercises for knee joint were included in the rehabilitation. He was rested from main matches and training session to enhance healing of hamstrings. Cryotherapy with compression through cryo-cuff machine was provided 5–6 times every day for initial 7 days. Cryotherapy is much more efficient at reducing pain, inflammation, and swelling compared to nonsteroidal anti-inflammatory drug. To maintain his cardio endurance upper limb workouts in the gym and backstroke, reversed breaststroke were performed in the pool 45 min every day.

Re-examination performed following 2 weeks of active release technique showed 85° pain-free passive knee extension on the right hamstring. His pain intensity while running was 4/10 and at rest was 0/10 in verbal rating score. There was no increase in circumferential measurement of thigh. On three trial average, the measurement on the right side was 60.1 cm. His gait has improved without pain and able to perform exercises in initial phase without pain. Hence he was progressed to the next phase. During this phase jogging, running, walking on high knees in the pool were initiated. Leg extension, squats, lunges, step ups, lateral step ups, cycling, and leg press were trained in the gym. Manual multiangle isometrics for hamstrings in pain-free range was done by the physio. Cryotherapy was applied as needed.

By the end of 3 weeks, passive knee extension was 90° bilaterally, and verbal rating score recorded 0/10 while running (with kinesiotaping). Gradually, Zakeer was traveling with the team to training session and performed differential training program. The differential training program included kicking movement with stiff knees or stiff hip, slack foot and circling arms, hopping run up, sprints, Jog-run-jog, etc., Zakeer's symptoms and his ability to perform differential program was monitored by the coach, strength and conditioning coach, physio and physician. All these were video recorded for analysis. He was able to do all activities without pain. After 4 weeks Zakeer Mundampara underwent functional tests of eccentric knee drop, broad jump test, single leg hop test, vertical jump assessment to participate in sports specific drills. Zakeer performed three trials of all the tests, and he was pain-free and comfortable. Sports and conditioning coach taught him sports specific drill activities which include lunge walking, shuttle running, diagonal running, bounding, scissor running, high knee running forward-backward, zorba running, single leg hopping, single leg diagonal hopping, hopscotch with side steps, fast feet – step and slide, zig-zag running, etc. He performed all sports specific drills with Kinesio tape to enhance proprioception. Return to play criteria [9] for Zakeer fulfilled the following; complete pain relief, muscle strength performance, subjective feeling reported by the player, muscle flexibility, specific soccer test performance, running analysis and balance control assessment. Fear of re-injury is a major concern for all athletes after any injury. Psychological fear of sustaining re-injury while reduces the performance of an athlete. Even after a perfect high-intensity sports specific drills or agility drills, this fear exists. In Zakeer's situation medical and technical staffs-physiotherapist, strength and conditioning coach, coach are all involved in getting out of this fear factor. The method of returning Zakeer to play without re-injury fear progressed from technical practice (like shooting, passes, dribbles, etc.) [Figure 1], playing practice match with division soccer team and with teammates, then return to play main match as substitute. This prepared his mind to overcome the fear of re-injury and makes him to deliver his 100% effort in the main match after return to play. Zakeer Mundampara was able to compete in these training practices without pain and discomfort, got himself in the squad for the main match and played a main match for 90 min.
Figure 1: Zakeer undergoing technical practice

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  Discussion Top

In this case study, the unique method of rehabilitation utilized only active release technique. George et al. analyzed the effect of active release technique on hamstring flexibility among twenty healthy subjects and showed that there is an improvement in hamstrings flexibility after active release technique.[7] Michael Leahy proposed a mechanism to explain increased tissue stiffness, or tension, called the “cumulative injury cycle.” In this cycle, repetitive micro-injury in tight muscles leads to an increase in the friction and tension what is termed the “chronic cycle,” or it leads to the “inflammation cycle” whereby a tear or crush injury ensues, followed by inflammation. Both of these cycles lead to the same result: An accumulation of adhesions and fibrosis within the tissue. This in turn increases the tightness of the tissue. Active release technique restores free and unimpeded motion of all soft tissues; it releases entrapped nerves, vasculatures, and lymphatics, it re-establishes optimal texture, resilience and function of soft tissues.[10] Although successfully alleviating pain is not enough. To return to play, the athlete had to perform sports activities without pain and discomfort, while maintaining proper technique. For example, the athlete had to be able to perform a sprint at 100% intensity and be able to kick or dribble a ball without pain. It is a major challenge to decide whether an athlete can safely return to play. In clinical practice, criteria to return to play comprises of pain-free full range of motion, 90% of the muscle strength tested isokinetically compared to the non-injured side and the ability to perform functional sports specific activities. A perfect decision on the return to play avoids re-injury. Re-injuries have classically been attributed to unsuitable rehabilitation protocols or returning to play too soon. Most re-injuries are due to this second factor. Furthermore, re-injuries seem to be related with playing position, where more explosive players (lateral defenders and wingers) seem to have a higher risk of re-injury. In this study, the intervention was provided for 2 weeks followed by 2 weeks of gradual training of sports specific drills and differential to return Zakeer safely back to play.

  Conclusion Top

Injuries are a major adverse event in a soccer player's career. This is the first case study that throws light into the effectiveness of active release technique in hamstring strain among a footballer. This study demonstrated the effectiveness of active release technique in muscle injuries. However, the duration of intervention and its effectiveness may varies among athlete and a nonathlete, which requires future studies in these areas in terms of a randomized controlled trial.


The authors their express gratitude to Dr. Clement Joseph (MS Ortho) for his expert guidance to complete this study. We thank Zakeer Mundampara who gave his consent to publish this case study. We thank Dr. Manoj Muthu, Dr. Shiva Reddy and Dr. Vivek Nigam for their support.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Ekstrand J, Hägglund M, Kristenson K, Magnusson H, Waldén M. Fewer ligament injuries but no preventive effect on muscle injuries and severe injuries: An 11-year follow-up of the UEFA Champions League injury study. Br J Sports Med 2013;47:732-7.  Back to cited text no. 1
Ekstrand J, Hägglund M, Waldén M. Epidemiology of muscle injuries in professional football (soccer). Am J Sports Med 2011;39:1226-32.  Back to cited text no. 2
Askling C, Lund H, Saartok T, Thorstensson A. Self-reported hamstring injuries in student-dancers. Scand J Med Sci Sports 2002;12:230-5.  Back to cited text no. 3
Brooks JH, Fuller CW, Kemp SP, Reddin DB. Incidence, risk, and prevention of hamstring muscle injuries in professional rugby union. Am J Sports Med 2006;34:1297-306.  Back to cited text no. 4
Askling CM, Tengvar M, Thorstensson A. Acute hamstring injuries in Swedish elite football: A prospective randomised controlled clinical trial comparing two rehabilitation protocols. Br J Sports Med 2013;47:953-9.  Back to cited text no. 5
Spina AA. External coxa saltans snapping hip treatment with active release technique: A case report. J Can Chiropr Assoc 2006;51:23-9.  Back to cited text no. 6
George JW, Tunstall AC, Tepe RE, Skaggs CD. The effects of active release technique on hamstring flexibility: A pilot study. J Manipulative Physiol Ther 2006;29:224-7.  Back to cited text no. 7
Senem G, Serap A. Immediate effects of kinesiotape on acute hamstring strain; case report. J Rom Sports Med Soc 2014;10:2305-8.  Back to cited text no. 8
Delvaux F, Rochcongar P, Bruyêre O, Bourlet G, Daniel C, Diverse P, et al. Return-to-play criteria after hamstring injury: Actual medicine practice in professional soccer teams. J Sports Sci Med 2014;13:721-3.  Back to cited text no. 9
Howitt S, Wong J, Zabukovec S. The conservative treatment of Trigger thumb using Graston Techniques and Active Release Techniques. J Can Chiropr Assoc 2006;50:249-54.  Back to cited text no. 10


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