Examination and treatment of hamstring related injuries

2019 Marathon of Rome. Hamstring injuries in long distance runners: influence of age, gender, weight, height, numbers of marathon and impact profile

BACKGROUND

Hamstring diseases are one of the most widespread diseases in athletes, especially in runners, sprinters, and endurance athletes. Notwithstanding the importance of the problem, risk factors are still marginally known. This transversal study analyzes the correlation between Hamstring tendinopathy and hamstring strains and age, gender, weight, height, number of marathons, and impact profile in athletes who took part in the 2019 Rome Marathon.

METHODS

At the 2019 Marathon of Rome, 700 runners (484 males and 216 females; mean age: 43.6 years, range 17-80 years) filled the VISA-H and FASH questionnaires. An adequately skilled orthopedic surgeon made a diagnosis of Hamstring tendinopathy and Hamstring strain injuries in line with clinical criteria.

RESULTS

A diagnosis of Hamstring tendinopathy was made in 537 participants while in 624 of hamstring strains. There was evidence of a positive correlation statistically significant between age, weight and impact profile with Hamstring strain injuries, while there was no association between sex and number of marathons and the Hamstring strains. No statistically significant positive correlation was found between all of the parameters analyzed and VISA-H. The association between VISA-H score and FASH score has resulted statistically significant.

CONCLUSIONS

In marathon athletes, there was not found evidence of a statistically significant correlation between gender, weight, height, number of marathons, impact profile and Hamstring tendinopathy. Nonetheless, age, weight and impact profile were associated with Hamstring strains, while sex and number of marathons had not shown statistically significant positive association with Hamstring strain injuries.

Portal placement for endoscopic surgery in the deep gluteal area: a cadaveric study

Partial or complete avulsion of the insertion of the proximal hamstrings at the level of the ischial tuberosity is most often treated by open exploration and reinsertion. However, endoscopic reinsertion could be considered to minimize the soft tissue damage. In this study, we aimed to determine the most optimal location of four endoscopic portals that allow for a safe exploration of the proximal hamstring insertion site. The reference points for the portals run vertically through the center of the sciatic tuberosity and through a horizontal line which lies on the inferior edge of the tuberosity. The distance and relationship between the sciatic, the inferior gluteal and posterior femoral cutaneous nerves and the four proposed endoscopic portals was documented. Our results showed that it was best to start with the inferior portal followed by the medial and lateral portal. The inferior portal allowed for a clear visualization of the sciatic nerve and was along with the medial portal at a distance of >5 cm from any of the surrounding nerves. Care must be taken with the lateral portal, as the distance to the surrounding nerves varied between specimens. A fourth portal could be used as a viewing portal when necessary. Our study showed that the sequence and position of the proposed endoscopic portals provide a safe approach to the proximal part of the hamstrings and the ischial tuberosity. These findings can be helpful for endoscopic procedures to the ischium and the sciatic nerve in the gluteal region.

Chronic ischial tuberosity avulsion nonunion fracture treated with a platelet-rich plasma injection as a bone graft

We present a case of an 18-year-old with a 2-year history of buttock pain who failed extensive treatment for a perceived hamstring strain. Upon evaluation, he was diagnosed with an ischial tuberosity nonunion avulsion fracture. The patient underwent bone grafting via an ultrasound guided leukocyte rich platelet-rich plasma injection followed by the use of a bone stimulator to enhance the bone healing. At 3 months, he was asymptomatic and had radiographic evidence of excellent bone healing. He remained asymptomatic at 1 year and had resumed full activities. This case report is the first in the literature to describe the treatment of a chronic ischial tuberosity nonunion avulsion fracture with the use of platelet-rich plasma as a bone graft.

Central Tendon Injuries of Hamstring Muscles: Case Series of Operative Treatment

Background:

As compared with injuries involving muscle only, those involving the central hamstring tendon have a worse prognosis. Limited information is available regarding the surgical treatment of central tendon injuries of the hamstrings.

Purpose:

To describe the operative treatment and outcomes of central tendon injuries of the hamstrings among athletes.

Study Design:

Case series; Level of evidence, 4.

Methods:

Eight athletes (6 top level, 2 recreational) with central hamstring tendon injuries underwent magnetic resonance imaging and surgical treatment. The indication for surgery was recurrent (n = 6) or acute (n = 2) central hamstring tendon injury. All patients followed the same postoperative rehabilitation protocol, and return to play was monitored.

Results:

Magnetic resonance imaging found a central tendon injury in all 3 hamstring muscles (long head of the biceps femoris, semimembranosus, and semitendinosus) with disrupted tendon ends. In acute and recurrent central tendon injuries, full return to play was achieved at 2.5 to 4 months. There were no adverse events during follow-up.

Conclusion:

Central tendon injuries of the hamstrings can be successfully repaired surgically after acute and recurrent ruptures.

Rehabilitation and return to sport after hamstring strain injury

Hamstring strain injuries are common among sports that involve sprinting, kicking, and high-speed skilled movements or extensive muscle lengthening-type maneuvers with hip flexion and knee extension. These injuries present the challenge of significant recovery time and a lengthy period of increased susceptibility for recurrent injury. Nearly one third of hamstring strains recur within the first year following return to sport with subsequent injuries often being more severe than the original. This high re-injury rate suggests that athletes may be returning to sport prematurely due to inadequate return to sport criteria. In this review article, we describe the epidemiology, risk factors, differential diagnosis, and prognosis of an acute hamstring strain. Based on the current available evidence, we then propose a clinical guide for the rehabilitation of acute hamstring strains and an algorithm to assist clinicians in the decision-making process when assessing readiness of an athlete to return to sport.

Hamstring Injuries in the Athlete: Diagnosis, Treatment, and Return to Play

Hamstring injuries are very common in athletes. Acute hamstring strains can occur with high-speed running or with excessive hamstring lengthening. Athletes with proximal hamstring tendinopathy often do not report a specific inciting event; instead, they develop the pathology from chronic overuse. A thorough history and physical examination is important to determine the appropriate diagnosis and rule out other causes of posterior thigh pain. Conservative management of hamstring strains involves a rehabilitation protocol that gradually increases intensity and range of motion, and progresses to sport-specific and neuromuscular control exercises. Eccentric strengthening exercises are used for management of proximal hamstring tendinopathy. Studies investigating corticosteroid and platelet-rich plasma injections have mixed results. Magnetic resonance imaging and ultrasound are effective for identification of hamstring strains and tendinopathy but have not demonstrated correlation with return to play. The article focuses on diagnosis, treatment, and return-to-play considerations for acute hamstring strains and proximal hamstring tendinopathy in the athlete.

Posterior, Lateral, and Anterior Hip Pain Due to Musculoskeletal Origin: A Narrative Literature Review of History, Physical Examination, and Diagnostic Imaging

OBJECTIVE

The purpose of this study was to present a narrative review of the literature of musculoskeletal causes of adult hip pain, with special attention to history, physical examination, and diagnostic imaging.

METHODS

A narrative review of the English medical literature was performed by using the search terms "hip pain" AND "anterior," "lateral," and "posterior." Additionally, specific entities of hip pain or pain referral sources to the hip were searched for. We used the PubMed search engine through January 15, 2016.

RESULTS

Musculoskeletal sources of adult hip pain can be divided into posterior, lateral, and anterior categories. For posterior hip pain, select considerations include lumbar spine and femoroacetabular joint referral, sacroiliac joint pathology, piriformis syndrome, and proximal hamstring tendinopathy. Gluteal tendinopathy and iliotibial band thickening are the most common causes of lateral hip pain. Anterior hip pain is further divided into causes that are intra-articular (ie, labral tear, osteoarthritis, osteonecrosis) and extra-articular (ie, snapping hip and inguinal disruption [athletic pubalgia]). Entrapment neuropathies and myofascial pain should also be considered in each compartment. A limited number of historical features and physical examination tests for evaluation of adult hip pain are supported by the literature and are discussed in this article. Depending on the clinical differential, the gamut of diagnostic imaging modalities recommended for accurate diagnosis include plain film radiography, computed tomography, magnetic resonance imaging, skeletal scintigraphy, and ultrasonography.

CONCLUSIONS

The evaluation of adult hip pain is challenging. Clinicians should consider posterior, lateral, and anterior sources of pain while keeping in mind that these may overlap.

Rehabilitation of proximal hamstring tendinopathy utilizing eccentric training, lumbopelvic stabilization, and trigger point dry needling: 2 case reports

STUDY DESIGN

Case report.

BACKGROUND

Proximal hamstring tendinopathy is a relatively uncommon overuse injury seen in runners. In contrast to the significant amount of literature guiding the evaluation and treatment of hamstring strains, there is little literature about the physical therapy management of proximal hamstring tendinopathy, other than the general recommendations to increase strength and flexibility.

CASE DESCRIPTION

Two runners were treated in physical therapy for proximal hamstring tendinopathy. Each presented with buttock pain with running and sitting, as well as tenderness to palpation at the ischial tuberosity. Each patient was prescribed a specific exercise program focusing on eccentric loading of the hamstrings and lumbopelvic stabilization exercises. Trigger point dry needling was also used with both runners to facilitate improved joint motion and to decrease pain.

OUTCOMES

Both patients were treated in 8 to 9 visits over 8 to 10 weeks. Clinically significant improvements were seen in pain, tenderness, and function in each case. Each patient returned to running and sitting without symptoms.

DISCUSSION

Proximal hamstring tendinopathy can be difficult to treat. In these 2 runners, eccentric loading of the hamstrings, lumbopelvic stabilization exercises, and trigger point dry needling provided short- and long-term pain reduction and functional benefits. Further research is needed to determine the effectiveness of this cluster of interventions for this condition.

LEVEL OF EVIDENCE

Therapy, level 4.

Treatment of hamstring strain in a collegiate pole-vaulter integrating dry needling with an eccentric training program: a resident's case report

BACKGROUND

Hamstring strain injuries are among the most common injuries seen in sports. Management is made difficult by the high recurrence rates. Typical time to return to sport varies but can be prolonged with recurrence. Eccentric strength deficits remain post-injury, contributing to reinjury. Eccentric training has shown to be an effective method at prevention of hamstring injury in multiple systematic reviews and prospective RCTs but limited prospective rehabilitation literature. Functional dry needling is a technique that has been reported to be beneficial in the management of pain and dysfunction after muscle strains, but there is limited published literature on its effects on rehabilitation or recurrence of injury.

PURPOSE

The purpose of this case report is to present the management and outcomes of a patient with hamstring strain, treated with functional dry needling and eccentric exercise.

CASE DESCRIPTION

The subject was an 18-year-old collegiate pole-vaulter who presented to physical therapy with an acute hamstring strain and history of multiple strains on uninvolved extremity. He was treated in Physical Therapy three times per week for 3 weeks with progressive eccentric training and 3 sessions of functional dry needling.

OUTCOMES

By day 12, his eccentric strength on the involved extremity was greater than the uninvolved extremity and he reported clinically meaningful improvement in outcome scores. By Day 20, he was able to return to full sports participation without pain or lingering strength deficits.

DISCUSSION

The patient in this case report was able to return to sport within 20 days and without recurrence. He demonstrated significant decreases in pain and dysfunction with dry needling. He had greater strength on the injured extremity compared to contra-lateral previously injured extremity.

CONCLUSIONS

This case illustrates the use of functional dry needling and eccentric exercise leading to a favorable outcome in a patient with hamstring strain.

LEVEL OF EVIDENCE

Level 4.