hamstring injuries in sport - fadi hassan

Ankle sprain and ligament injury

Hamstring injuries in sportFadi HassanHull York Medical School

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AnatomyEpidemiologyMechanism of injuryClinical features History takingExamination and imagingTypes of strain and gradingRisk factorsManagement Rehabilitation and conditioningReturn to playPsychological impactPreventionOverview

Anatomy

Hamstring part of adductor magnusLong head of biceps femorisShort head of biceps femorisSemitendinosusSemimembranosusFunctionsHip extensionKnee flexionInternal rotation of the hip when the knee is flexed

Hamstring muscles occupy the posterior compartment of the thigh, and they consist of; semitendinosus, semimembranosus, and biceps femoris (long and short head).

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Anatomy

Sciatic nerveTibial nerveCommon fibular nerveLong head of biceps femoris and semitindonsus and semimembranosus cross both hip and knee joints and are innervated by tibial part of the sciatic nerve. Short head of BF cross only knee joint and is innervated by the common fibular part of the sciatic nerve

Sciatic: damaged when giving intramuscular injections in the gluteal region if the injections are not done in the correct location

Irritation or compression of the anterior rami of spinal nerves (L4-L5) can result in sensory and motor dysfunction of the sciatic nerve. Diffuse pain from the area of distribution of sciatic nerve is termed sciatica

Common fibular: courses laterally around the neck of the fibula where it can be damaged by impact or compression injuries. Damage can lead to footdrop (inability to dorsiflex the foot) and to sensory loss over the lateral leg and dorsal surface of the foot.

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Biceps FemorisOrigin: Ischial Tuberosity (L - MFCT) lower linea aspera of femur (S)Insertion: Lateral condyle of tibia (L)Head of fibula(S)Innervation: Tibial part of sciatic nerveSemitendinosusOrigin: Ischial tuberosity (medial facet CT)Insertion: (Upper) medial condyleInnervation: Tibial part of sciatic nerveSemimembranosusOrigin: Ischial tuberosity (LF)Insertion: Posterior of medial epicondyle of tibiaInnervation: Tibial part of sciatic nerve

Common tendon goes from medial facet of ischial tuberosity. ST originates from the medial aspect of the common tendon. BF originates from the lateral aspect of the common tendon about 6cm below the ischial tuberosity.SM originates from the lateral facet of ischial tuberosity and extends medially passing deep to the ST/BF proximal tendon.Short head originates from linea aspara thus only crosses knee joint and only acts on that5

EpidemiologyFigures forBritish footballAustralian footballRecurrence rateSpecific strains

British footballHamstring strains make up 12% of injuriesThats 5 injuries per club per seasonAverage injury causes the player to miss 2-4 matchesAustralian football15% of all injuriesRecurrence rate12% in british football34% in australian footballEpidemiology of specific strainsBiceps femoris strain (76-87%)Semimembranosus uncommonSemitendinosus - rare

Mechanism of injury and clinical featuresit comes on suddenly like a cyclist getting a puncture. It was like someone getting up and slapping me around the face Derek Redmond (Barcelona 1992)

MechanismMuscle strain to large muscle group is the result of substantial force and it may be related to an eccentric contraction due to high-speed sprinting for example (Type I) or it may be associated with an excessive stretching (Type II)

Clinical presentationA disabling pain with Sudden onset (moderate-severe) and marked reduction in strength and ability to stretch the muscle. Pain against resistance and focal tendernessHaematoma and bruising May have abnormal signs on ultrasound/MRI.Always leads to the player leaving the field holding the back of his/her thigh.Gluteal pain

HistoryCan they remember when/why the injury happenedYes Strain, fascial/neural traumaNo Overuse, referred painSite of pain and radiationPresence of neurological symptomsProgress since injury to assess the severityAbility to walk without pain within 24 hours after the injuryYes better prognosisNo longer rehabilitation time (>3wks to RTT)Ask if the athlete has adapted any change in his/her training regime recently.Ask about any fluctuations in activity level (overtraining?)Aggravating factors:Incident related include that in rehabilitation program (acceleration)Non-incident related modification/preventionRelation to sports Helps in your differential diagnosisSudden onset MechanicalIncrease with activity inflammationStart with minimal pain then builds up with activity (not severe) think of vascular or neurological causesIs it a recurrence injury? Have they had any problems with hamstrings in the past?

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Differential Diagnoses of posterior thigh painDDx: tearing of neural structures, fascial strains, referred pain, tendinopathy, bursitis, fibrous adhesions, nerve entrapment, adductor magnus strain, myositis ossificans.It is crucial to determine the origin of the pain as this will direct how you manage the injury.Importance of examinationReferred pain vs low grade strain both show no evidence on MRI, making it hard to establish the origin of the painEfficient history and thorough examination will be crucial in this case.Monitoring the progress of the injury will determine the nature of the injuryNo MRI evidence of strain chronic posterior thigh pain with no response to management and rehabilitation more likely to be referred pain.

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Examination & ImagingExamination and special testsImportance of imaging and what can be seen on them

ExaminationInspect for bruising, muscle wasting or swelling Standing, walking, lying pronePalpationHamstring muscles, ischial tuberosity, gluteal muscles (trigger points/taut bands)Active movements: Lumbar movementsHip extensionKnee flexionActive knee extension and hip flexionHip is flexed to 90 degrees with the knee initially flexed at 90 too and then the knee is slowly extended till pain is felt and then to the end of the range.Passive movementsHamstring muscle stretch: leg raised to the point where pain is felt, and to the end of ROM.Resisted movementsKnee flexionHip extension

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Examination - TestsFunctional testsRunningKickingSprint startSlump testdifferentiates between hamstring muscle injuries and referred pain from the lumbar spine.Helps to diagnose nerve root injury and is considered positive if pain exists. Patient seated at the edge of the bed (90 degrees), hands behind the backIt contains multiple components that include active thoracic and lumbar flexion apply passive pressure to maintain that position.Active head flexion actively extend the knee foot dorsiflexionNegative in hamstring strainLumbar spine examination

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ImagingMRI: can show edema in hamstring region as well as tears in the soft tissue. It is non-invasive and provides high resolution images. It can easily identify the type of tissue involved and the location of the injury which helps in predicting prognosis.Image below: Type I (Left), Type II (Right)Ultrasound: hypoechoic areas (less echogenic than other areas darker than normal)CTInjury location can be determined on palpation (maximal pain point) and by MRI during the first 2 weeks after injury

BFProximal free tendon of SM16

Grading and types

TypesType I (more common)Caused by a heavy load on the hamstrings (during high-speed running, kicking, jumping)Usually involves the long head of biceps femoris (more commonly Proximal MTJ)Causes a marked acute decline in function but usually require a shorter rehabilitation time than type IIType IIDuring movements leading to extensive lengthening of the hamstrings during hip flexion such as high kicking, slide tackle, sagittal split which may or may not occur at slow speed.Usually located close to the ischial tuberosity and involves the proximal free tendon of SM.Less acute limitation, but their rehabilitation period is likely to be longer.Injury location can be determined on palpation (maximal pain point) and by MRI during the first 2 weeks after injury.THE CLOSER THE SITE OF INJURY TO THE ISCHIAL TUBEROSITY, THE LONGER THE REHABILITATION TIME.

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Figure 1: Schematic drawing showing the six different regions used when analysing the injury location and tissues involved. 1. proximal tendon (PT) 2. proximal muscle-tendon junction (PMTJ) 3. proximal muscle-belly (PMB) , 4. distal muscle-tendon junction (DMTJ) 5. distal muscle-belly (DMB)Figure 2: Distance between the most cranial pole of the edema and the ischial tuberosity is shown as the double-headed arrow in 2 different types of injury. The edema starts caudal to tuber in the left and cranial to tuber in the right MR-image.

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GradingGrade 1Discomfort in the back of the thigh and inability to operate at full speedCan walkLittle swellingGrade 2Gait will be affected and they will most likely end up limping off the pitchSudden pain which gets worse on activity or on resisted movementsSore to touchGrade 3Tear involving half/full muscleInability to walk and may need crutches Severe pain and weaknessSwelling and bruising are both noticeable

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Risk factors

Risk FactorsIntrinsic (person-related)AgePast historyPresence of scar tissue high rates of localized tissue strains in the adjacent muscle fibers further injuryHamstring strengthReduced predisposition to strainsReduced quadriceps flexibilityPoor lower limb proprioceptionRunning style (Michael Owen with his upper body flexed/leaning forward putting a higher load on the hamstrings)Extrinsic (environment-related)FatiguePlayer positionGK have significantly lower risk than outfield playersWide players at risk due to high intensity of their accelerationRecurrence risk factorsSize of previous lesions: Larger lesions higher chance of recurrence.All the above

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Management and rehabilitationRehabilitation programs should never be a recipe. Each case should be treated on its merits Peter Brukner

Management in the first 24 hoursThe first few days are crucial in hamstring injuries. Management here aims to facilitate myofiber regeneration and to minimize fibrosis in order to reduce the chance of recurrenceRICERest, Ice, Compression and ElevationApplying ice for 10-15 minutes using cold packs, every 3-4 hours (for the first few days).Compression with an elastic bandage or tubigrip stockings.Muscle activationFrequent low-grade + pain-free muscle contraction regimes immediately after injuryAngiogenesis and expansion of existing vascularity increase delivery of muscle-derived stem cells myofiber regeneration and accelerated repairTheres a great american paper on muscle injury and repair. I will post the link at the end of this presentation.Medical therapiesNSAIDs (evidence?)Simple analgesicsGrowth factors to accelerate healing (PRP and autologous blood)Injections of traumeel S and Actovegin immediately after the injury and again at days 2 and 4 post-injury to the area of injury enhance aerobic oxidation.

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RehabilitationStart once the patient can walk without pain (4-6 days)Light jogging increase intensity gradually pain should always be the indicator rather than progressing according to a time-frame as this period is very dangerous (weak tissue high risk of re-injury)Stretching: Increases rate of recovery and minimizes long term loss of ROM by minimizing the scarring formationHip flexors: tight high risk of hamstring strains

Progression should not be time dependent (minor injuries can take extended periods for full recovery).

Pain is always the indicator this period is dangerous because healing process is in its initial stages, and the risk of re-injury is high since the injured tissue is less able to absorb energy.

Focus on tight hip flexors (iliopsoas + other) that may place you at risk of increased risk of hamstring strains

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Rehabilitation Soft tissue treatmentSoft tissue treatment and mobilizationLumbar spine, sacroiliac, and buttock regionsStretch with bent knee and then add a little bit of cervical flexionDigital ischaemic pressure and sustained myofascial tensionGently first and then more vigorously Hand or elbow kept on the hamstrings, release is performed by PASSIVELY extending the kneeMassage along the muscle may assist in scar reorganizationElbow ischaemic pressure with the tissue on stretch and the muscle contracting (side-lying position) gluteal abnormalities

Lumbar spine, sacroiliac and buttock tight? Problems ? Contribute to posterior thigh pain

Locate the center of the spasm in the tensor fascia lata just anterior and superior to the greater trochantor. Contact the strain with your thumb and push posteriorly and medially, maintaining steady balanced pressure, until a release occurs.

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Rehabilitation Strengthening hamstring mucsles

Includes eccentric muscle contractions and excessive lengthening (simultaneous hip and knee flexion)Standing single-leg hamstring catches with theraband

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Includes eccentric muscle contractions and excessive lengthening (simultaneous hip and knee flexion)b. Single-leg bridge catch

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Includes eccentric muscle contractions and excessive lengthening (simultaneous hip and knee flexion)C. Single-leg ball rollouts

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Includes eccentric muscle contractions and excessive lengthening (simultaneous hip and knee flexion)D. Single leg deadlifts with dumb bell

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Includes eccentric muscle contractions and excessive lengthening (simultaneous hip and knee flexion)E. Yo-yo (Eccentric hamstring curls)

If the video doesnt work just look it up on YouTube

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Includes eccentric muscle contractions and excessive lengthening (simultaneous hip and knee flexion)F. Bridge walk-outs


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Includes eccentric muscle contractions and excessive lengthening (simultaneous hip and knee flexion)G. Nordic drops: develops hamstring strength and efficient in preventing recurrence of injury


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Rehabilitation What else can you do?Strengthening hamstring synergistsIf theyre weak overload on hamstring injury or re-injuryGluteal muscles and adductor magnus.One-legged bridging, squats and split squats (one-leg).Neuromuscular controlLumbopelvic stability: single leg balance on a ballSingle-leg windmil touches (shown below)BalanceCore strengthExtreme stretchOsteopathic techniquesHydroworx

http://www.youtube.com/watch?v=k6I15aN8Q_ULumbar spine, sacroiliac and buttock tight? Problems ? Contribute to posterior thigh pain34

Osteopathic techniquesMuscle energy technique (MET)Osteopathic manipulative treatment for decreased ROM and muscular dysfunction.The lower extremity is taken to a point of tension in the posterior muscles and held thereThe patient is then asked to push the leg against the shoulder for 6 secondsAfter relaxing, a new motion barrier is found at a greater degree of flexionThe process is repeated usually 3 times to achieve a state of enhanced stretchThe resistance by the patient should always be no greater than 25%

Lumbar spine, sacroiliac and buttock tight? Problems ? Contribute to posterior thigh pain35

Osteopathic techniquesKneading massageSwedish massage tradition that seems to be very effective for sore muscles by manipulating and loosening the muscle fibers.With the hands apply a firm, circular kneading motion by pulling half the muscle towards you with the fingers of one hand and pushing half the muscle away with the thumb of the other hand Then reverse to manipulate the muscle in the other directionTry to cover as much muscle as possible for five minutes approximately.

PMPL


Osteopathic techniquesIliotibial bandWith the patient lying supine, locate the tightest point in the tract along the lateral aspect of the thigh. Using the pad of your dominant thumb, reinforced by your other thumb, press medially and posteriorly on this point. Maintain this balanced pressure until a release occurs.Myofascial release of hip adductorsLocate the specific muscle in spasm on the medial aspectWith the pad of the thumb, push towards the femur superiorly and laterally maintain that until the muscle relaxes

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Kinesio tapingBenefits?Improves circulationSupport muscleHelps healing and prevent muscle injuryActivate endogenous analgesic systemUsually lasts 3-5 days and it is sweat and water proof.gently lifts the layer of skin and attached tissue covering a muscle (fascia) so that blood and other body fluids (blood and lymphatics) can move freely in and around the muscle.Kinesio vs Old-school taping methodsOld school taping: Theyre efficient in preventing further strain by immobilizing the joint BUT they tend to block or partially block the circulation slowing healing processes.Kinesio allows full movement but they stabilize the muscle at the same time prevent over contraction and over extension

Return to playIncidence of recurrence is too high (1/3 with greatest risk being at the first 2 weeks on RTT)

Return to competitionRunning could start when the sportsperson is comfortable running at 50% intensity. With the right program, the sportsperson can slowly return to sport (with sufficient rest to assess the effects of the load).Return to sport criteriaAbsence of clinical signs with normal ROMSuccessful completion of running program (20m time comparable to previous time when uninjured)Successful completion of appropriate rehabilitation exercisesSuccessful completion of at least 2 training sessions at maximal exertionGame time can be minimized on the first few games, then gradually increased to full time in order to prevent recurrence and fatigue.Game time can be minimized on the first few games, then gradually increased to full time in order to prevent recurrence and fatigue.In mild hamstring strain, this phase would be achieved in 12-18 days and most cases should resolve within 25 days (apart from severe strains and ruptures).More efficient rehabilitation regimes are more focused towards return to COMPETITION and PERFORMANCE rather than just return to training. The muscles might seem OK on an MRI but that does not always mean the athlete is ready to return for training or for high intensity workouts


Return to competitionAsklings H-test and dynamic isokinetic strength testingRecent test developed by a Swedish doctorResearch showed it can detect problems with hamstring muscles that are not picked up by examination. The muscle might function normally but sometimes it can still have micro-tears that would still compromise its strength.So this test involves flexing all the lower extremity joints by applying a brace and the patient would then be asked to perform leg raises repeatedly and compare that to the other leg. resistance can be appliedAny discomfort signals to a potential problem.

Loading How far can we go?Re-injury often happens due to insufficient rehabilitation and conditioningPoor rehabilitation (by maybe not putting enough load) Strength remains untested the player starts in a competitive game in which the load and volume of work is a lot higher than training sessions re-injury.


Complications and psychological effectsThe main complication is often re-injury and spending a very long time out of the game which might lead to further problems.I will discuss the psychological effects of the injury and re-injury

Psychological effectsFrustration, denial, anger and even depressionFear that it might come back affecting the way you playConcerns about losing place in first teamIf theres a big game soon, an injury like hamstring strain could leave a serious psychological effectsRe-injuryBeing on the bench depressionSense of injustice Why me?Impact that it could have on the teamLosing an important player could affect the teams confidence on the dayStress vs hamstring strainSome studies suggest stress and anxiety before the game could lead to hamstring strainsMental pressure increased muscular tension negatively affects physical performance high risk of injury

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Prevention

PreventionIsometric Muscle Voluntary Contraction (MVC): post-games for injury-prone playersAny reduction in MVC warning sign training load is reduced Useful particularly in those who already had this injury beforeSufficient rest between training sessions and gamesNordic drops: Proven by few studies to decrease the incidence of new and recurrence casesProprioception and balance exercises3 year German study involving 24 elite female football players from 22.4 to 8.2/1000 hoursThe more minutes of balance training, the lower the rate of hamstring injuriesSoft tissue therapy: Mobilization and manipulation.Activity modification for those at riskFIFA 11+A complete warm-up programme implemented by the F-MARC/FIFA to reduce injuries.Teams that performed the FIFA 11+ at least twice a week had 30-50% fewer injured players.Implemented by Real Madrid, Barcelona,Olympique Lyonnais, Spain and Japan. More teams have started to implement this recently.You can download the programme from this link:http://f-marc.com/11plus/home/

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Evidence Based MedicineI recommend you reading the following papers, they go into fine details regarding muscle injury hamstrings specifically.Muscle injuries (Biology and treatment) The American journal of sports medicineHamstring muscle strain Carl AsklingHAMSTRING INJURY REHABILITATION AND PREVENTION OF REINJURY USING LENGTHENED STATE ECCENTRIC TRAINING: A NEW CONCEPTRecurrent hamstring muscle injury: applying the limited evidence in the professional football setting with a seven-point programme Peter Brukner

Thank You!Fadi [email protected]

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hamstring injuries in sport - fadi hassan

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