Transcript Hamstring Tear - Learning

Hamstring Tear
Dr Riaan Barnard
MB,ChB
BSc Hons
M Sport Med (3’rd year)
Biggest set of “Hams” in SA !
Case History
• Mr Chris Howes, Triathlon Athlete, aged
45, tried a dry Slalom take-off on 22/12/10
• Slipped, ended in “splits”, felt sharp pain
mid-upper section L hamstring, feeling of
“something shearing off”
• Immediately couldn’t walk – limped back
• Took some NSAIDs, ice & pain meds,
Kinesio Tape and “hoppled along” rest of
vacation
• Saw Dr v Hagen on 3/1/11 for sonar
Sonar Results ??
• Showed very large, hypoechoic area of
5,5 x 4,5cm in mid-upper Biceps Femoris
section L
• Diagnoses of Grade II – III Hamstring Tear
was made
• Previous History:
• No previous hamstring tears / injury
• Lower back injury last 6/12 – saw Chiro
regularly for manipulations
Clinical Examination
• Large bruised area whole hamstring area
with extravasation into popliteal fossa
• TP’s palpable surrounding area & Gluteus
• Ext knee - resulting pain in hamstring
area
• Hamstring muscle stretch test positive
• Eccentric hamstring contraction pain ++
• No neurological deficit / neg Slump test
Diff Diagnoses / Spec
Investigations
• Grade II Hamstring Tear – Biceps Femoris
+ possible Semimembranosus
• Caused by sudden forceful eccentric
stretching, possible predisposing factor
large hamstring muscle, not warmed up
by stretching, possible stiffness due to
contributing back problem?
• Serial Sonars were done with each
subsequent PRP injection follow-ups
3-Stage Summary
• Personal / Psychological:
Not being able to compete in the 2011 Iron
Man Series
Social / Contextual:
Felt he was letting his fiancé down, as he
is her training partner for Iron Man
Plan & Progression
• Consulted me on 5/1 for PRP injection. Sonar directed
5cc volume injected into hypoechoic area.
• Initiated straight leg hamstring stretches + active kneeextensions to point of pain. Ice and Tramacet prn – no
NSAIDs !
• Sent to Chiro for Lumbo-sacral hypo-mobile segment to
be manipulated, as well as soft tissue treatment, dry
needling for surrounding TPs
• On 8+9/1 swimming slowly in pool + continued
stretching & strengthening exercises
• On 14/1 did slow 2-3km jog the morning – pain free.
Later that afternoon PRP nr 2. Hypoechoic area shrunk
to 3,5 x 2,5cm with new tissue formation visible
Progression continued…
• On 15/1 did slow 100km cycling race – pain free
• On 21/1 did 10km run – pain free
• Last PRP nr 3 injected on 26/1 – hypoechoic area
shrunk to 1,5 x 0,5 cm
• Did Half-Iron Man in East Londen on 29/1. Strapped the
leg with Kinesio Tape and finished the race in better
time than previous year ! Qualified for Iron Man April
2011
• What assisted a lot in this case, was the athlete’s
background on rehab of injuries. It was thus easy to
give him a copy of B&K pg 453 – Progressive Running
Protocol and the Criteria for RTS to be followed
Sonar guided PRP injections
Continued…
Discussion
• Well described chapter in B&K pg 443-453
Epidemiology & Biomechanics of Injury :
• Sprinters, hurdlers, long jumpers, football
players and dancers
• Most common in sports high-speed running &
kicking – biceps femoris most common injury.
Athletes immediately stop with injury
• In dancers slow stretch movement at the end of
range of movement (front & side splits) causes
87% cases of prox tendon of
semimembranosus. Dancers are often able to
continue dancing immediately after the injury
Predisposing Factors to Injury
• Intrinsic Factors:
These include
- Age
- Previous Injury
- Race
- Flexibility
- Strength
- Neuromyofascial
- Lumbopelvic Stability
- Joint Dysfunction
Extrinsic Factors:
- Warm-up
- Fatigue
- Fitness Level
- Training Modalities
Review Article: Mann et al
Three groups of Hamstring Injuries:
1. Proximal affecting common hamstring origin.
Divided into 3 categories:
- Tendon injury with full detachment ischium,
found mostly in adults
- Partial tears & overuse micro traumatic
tendon tears in adults & children
- Apophyseial overuse or acute damage with
or without avulsion, mainly in children
2. Central hamstring injuries of muscle bellies
3. Distal injuries affecting distal tendon or
tendon insertions
Proximal Injuries
• Proximity of sciatic nerve important – oedema &
inflammation lead to irritation, leading to false
impression of spinal nerve root compression
• Thus strong argument exists to reinsert
disrupted prox hamstring tendon to origin on
ischium, both to regain function and preserve
sciatic nerve from later damage
• 3 Stages of Apophyseal damage:
apophysiolysis, avulsion and non-united
avulsion fracture
• Union in widely displaced avulsion require 1-2
yrs. Avulsion > 2cm has common non-union and
surgical repair should be considered
Central Hamstring Injuries
• Theories:
- Type II muscle fibers responsible for explosive
force, more abundant in hamstrings than quads
- All hamstring muscles innervated by tibial
branch of sciatic nerve, except short head
biceps innervated by peroneal branch of sciatic
nerve – leads to forceful, uncoordinated
contractions, or simultaneous contraction of
hamstrings and quads
Brunet & Hontas’ Classification
• Grade I:
Small area, little haemorrhage and no structural
damage
• Grade II:
Felt “pop” or tear, immediate function loss,
swelling, palpable painful mass, definitive
structural damage
• Grade III:
Complete tear, mass of palpable muscle, mass
retracts on muscle activation, defect seen best
at 2-3 weeks
Distal Injuries
• More frequently the tear takes place in the
distal insertion of the Biceps Femoris
• Semimembranosus distal tendon is rarely
ruptured
• Most full ruptures should be repaired at an
early stage, followed by 5 weeks of cast
immobilisation
• Semitendinoses tears should be left alone and
not surgically repaired – little morbidity is
caused by its absence when used as graft in
ACL repairs
Take Home Message / Learning
Experience
• Using PRP sonar guided injections
work very well in acute muscle tears of
the hamstring muscles and
dramatically reduces return-to-play
time !!
References
1.
2.
3.
4.
5.
Brukner, P; Khan, K. Clinical Sports Medicine,
Third Edition. 2008. pg 443
Deleget, A. Overview of Thigh Injuries in Dance.
Journal of Dance Medicine & Science. 2010, vol
14(3), pg 97-102.
Koulouris, G; Connell, D. Imaging of Hamstring
Injuries: Therapeutic Implications. Eur Radiol
(2006) 16: 1478-1487
Mann, G; Shabat, S; Friedman, A; et al. Hamstring
Injuries. Orthopedics/ORTHOsupersite.com
Wehling, P; Moser, C; Frisbie, D; et al. Autologous
Conditioned Serum in the Treatment of Orthopedic
Disease. Biodrugs 2007: 21(5): 323-332