Zemgus Girgensons’ hamstring injury analysis

How serious is Girgensons’ injury and when will he return?

After 9 months without Buffalo Sabres hockey, to see players back on the ice at KeyBank Arena was a welcome sight. Lines began to take shape, defensive pairings shuffled around, and talk of returning to the postseason after a long overdue absence renewed.

Barely a week into practice, those plans took a hard left turn on January 4th with the injury to projected 3rd line winger Zemgus Girgensons seen below.

I had originally thought that he suffered either a groin strain or the possibility of a knee collision based on the limited video available, but reports came out indicating that it was more severe than originally thought.

The official diagnosis of the injury is a left hamstring injury that will keep him out for 6 months, effectively ending his season. It was reported that he had surgery to repair the hamstring on January 6th. Looking at the available video, he is shown having significant difficulty trying to place weight through his left leg, requiring assistance to get off the ice.

To review, the hamstrings are made up of 3 powerful muscles in the back of the thigh: the biceps femoris, semimembranosus, semitendinosus. These muscles allow for the leg to extend at the hip proximally and bend the knee distally. This allows for running and walking, driving the body forward in stance phase.

Usually, hamstring strains occur when the leg is going into stance phase where the muscle is lengthening under tension, also known as an eccentric contraction. A sudden overload results in the muscle failing to varying degrees anywhere from a few muscle fibers tearing to the entire muscle ripping from the bone.

Normally, most hamstring injuries do not require surgery and can heal on their own with varying degrees of severity affecting return to play timelines. In the case of Girgensons, it appears as though he suffered a proximal hamstring avulsion injury. This occurs when the tendon pulls away from the bony attachment and takes a piece of bone with it. In this specific case, his was the result of eccentric hip flexion and knee extension as seen in the video above. He got hit and tried to stay up on the ice, but the effort required to overcome that was too great and the muscle likely tore, leading to the injury.

There is a possibility that he could have suffered a distal hamstring avulsion tear, closer to where the hamstring connects at the knee. According to research, these don’t happen very often and there is less literature to support this injury.

This was a freak accident that could not have been prevented or had any injury prevention training. The area where Girgensons likely tore from is called the ischial tuberosity on the bottom of the pelvis see in the picture below where the hamstring would normally attach.

As mentioned above, this is a 6-month recovery but it will possibly take longer to fully return to full strength to play for the 2021-2022 season. Looking at the rehab protocol, it is a very slow process to return to full strength. The rehab protocol is here, but the main points are below:

  • The first 6 weeks are no weight bearing on crutches with no active movement with the use of the hamstring. Leg movements need to be limited in order to reduce stress on the healing area.
  • Once the surgeon has confirmed the muscle has healed back to the bone, then the process of weight-bearing may begin with gentle movements in other planes of motion to create stability and slowly stress the healing area.
  • After 3-4 months, further hamstring strengthening may begin along with stretching to begin returning to normal functions. This is progressed through higher-level strengthening and balance activities until months 5-9 in order to begin returning to sport.
  • Criteria to fully return to sport include no pain with activity, normal range of motion, and hamstring strength at least 75% of the non-involved leg both concentrically and eccentrically. /

If he had suffered the distal hamstring avulsion, return to sport is between 4-6 months according to rehab protocols. The initial reports of 6 months likely would have been reflected to show that he could return for a portion of the season if this were the case. The timeline along with the mechanism of injury would suggest the proximal hamstring avulsion over the distal portion along with the stated timeline.

Girgensons’ biggest challenge will be regaining the strength necessary to skate in every direction and accelerate down the ice. This article does an absolutely fantastic job of explaining the biomechanics of skating and how players can improve their speed and reduce their injury risk. There are certain qualities of fast skaters including increased ankle dorsiflexion, maximal hip extension, and knee extension. Regaining the strength in the hamstring required for hip extension will take some time in order to regain the speed and acceleration he had prior to the surgery. This article does a great job at also identifying the sport-specific injuries and needs in rehabilitating hockey players following injuries.

According to research, the studies show that there are favorable results to return to sport. Between 76-100% of participants return to sport, and 55-100% return to pre-injury levels. On top of that, the re-rupture rate is very low with rates at 3%. There isn’t a lot of research I’ve found specific to this injury in the NHL or hockey in general, then again, this is a rather traumatic injury. It is important to note that strength eventually returns to 75-100% compared to the uninvolved side.

I would anticipate that Girgensons regains his full function considering he has all the resources available to him as a professional athlete. Even if the Sabres make a surprising deep playoff run, I wouldn’t anticipate that he would be ready to play as the 6th month would open the window to begin the process to return to sport. The Stanley Cup playoffs begin in mid-May and the last day of the playoffs would be July 15th. He would need to work on conditioning and working back into game form during the month of June which would be difficult to raise his game to a playoff level by then. It’s not impossible, but it would be a very tight window and he would likely still not be at full strength.

By the time the 2021-2022 season begins, there should not be any noticeable effects of the injury. His quality of play may be affected due to having been off from hockey for at least 18 months from the March shutdown to when the next season starts.

According to reports, the NHL is looking to start with a regular season in the fall which will give Girgensons nearly 10 months to be fully ready to play in a game. This was a highly unfortunate injury that occurred to a long-tenured member of the team. The hope is that the team can continue on without him in the coming season and then add him back into the lineup next season to shore up weaknesses as the Sabres attempt to compete for division titles and become regular participants in the playoffs to challenge for conference and league championships.