Transcript ISSUES FOR REHABILITATION OF A HAMSTRING INJURY

HAMSTRING INJURY
The accuracy of MRI in predicting recovery and
recurrence of hamstring muscle strains




Dr N Gibbs
Dr T Cross
Mr M Cameron
Dr M Houang
J Sci Med Sport. 2004 Jun
1.
Introduction
2.
Literature review
3.
Methods
4.
Results and Discussion
5.
Conclusions
6.
Questions??
Clinical Scenario
e.g.. Posterior thigh pain 7 days
before World Cup Final
Can he play??
1. Introduction
Objective
1.
2.
To describe the MRI findings of a series of acute
hamstring muscle strains (i.e. “posterior thigh pain”)
Do these MRI findings help
1.
2.
Predict the PROGNOSIS
Predict The RECURRENCE RATE
Setting

Sydney Swans
Football Club

1 of 16 clubs
in the National
competition
Design
Prospective study over 5 years
(1999-2003):
Both in-season and pre-season
periods
Patients
40 professional footballers
Consent from Club and
individual players
Australian Rules Football
“Athletes at risk”




Repetitive sprinting efforts
Repetitive kicking
Repetitive jumping &
landing
Game time approximately
100 minutes
Australian Rules Football
Ideal sport ( “outdoor laboratory”)
to study muscle strain injury
Australian Rules Football
Hamstring strain is the most
significant injury in ARF
(Quadriceps strain in top 10)
Motivation for research

To better understand/diagnose Hamstring
muscle strains

To better manage/rehabilitate Hamstring muscle
strains
Motivation for research

To make an EARLY ACCURATE
PROGNOSIS
(i.e. we were unable to clinically differentiate
benign from serious Hamstring strains)
Motivation for research

To better understand which “hamstring”
injuries recur
2. Literature Review
Anatomy
Hamstrings, an “at-risk muscle”

Acts eccentrically

Crosses two joints

High % fast twitch fibres
Function
Main Function during sprinting
And kicking is to deceleration
of knee extension and hip
flexion
AFL injury database

Cause 20% of all
missed AFL games

Recurrence rate 34%
Literature review
Pomeranz (1993)
•
Retrospective study of Hamstring strains
•
n=14
•
Prognosis associated with size (cross-sectional
area%) of muscle strain injury on MRI scan
3. Methods
Methods
Inclusion criteria
1.
History
acute onset of posterior thigh pain/ache or tightness
while training or playing
2.
Examination : tenderness over the posterior thigh
: other signs elicited but not the subject of this study
Methods
Exclusion criteria
1.
History of trauma to posterior thigh (Contusion)
2.
Delayed onset of posterior thigh pain (DOMS)
3.
Recurrence of posterior thigh pain in ipsilateral
thigh in same season
Methods
MRI within 24-72 hours
•
T1,T2 with fat suppression, STIR
•
Axial, coronal planes (both thighs imaged)
(Axial T2 with fat suppression most useful images)
Methods
Muscle strain injury=
high signal on T2
weighted images
Methods
MRI diagnosis
Location (MRI category)
1.
2.
Which Hamstring muscle (s) injured
Location of injury with respect to known
musculotendinous junctions
Methods
MRI diagnosis
Size
1.
Cross sectional area % (CSA)
2.
Length (cm)
Methods

CSA% estimation (“dot” method)
Estimation of Length
Methods
MRI diagnosis: miscellaneous features…
•
T2 hyper intensity
•
muscle fibre disruption
•
Perifascial fluid
•
Scarring/fibrosis
Methods
What if more than one muscle injured?
(i.e. double injury etc.)
1.
Primary muscle injured= greatest CSA%
2.
Secondary muscle injury= smaller CSA%
Methods (rehabilitation phase)

No universally accepted rehabilitation regimen
exists for muscle strain injuries
Methods (rehabilitation phase)
Rehabilitation was standardised
Phase 1 : Acute management

RICE/crutches first 48 hours

Intensive Physiotherapy
•
•
•
soft tissue therapy
flexibility
strengthening
Methods (rehabilitation phase)
Phase 2: Remodeling phase


Eligible to start running program when,

Full pain free ROM

Complete 3 x 10 repetitions of single leg hops pain free
4 Stage running/kicking program (sport specific to ARF) was
designed at beginning of study
Methods (rehabilitation phase)
4 stage running/kicking program

Run alternate days
Physiotherapist/Sports Scientist supervision
Combined with intensive physiotherapy

5 minute jog warm up/cool down

Stage 1 : jog 10 mins x 2

Stage 2 : 80m intervals ( 40-60 %) 3x 5 repetitions

Stage 3: 80m intervals (90-100%) 3 x 5 repetitions (staged kicking program
commenced)

Stage 4: 80m intervals (sport specific drills at 90-100%) 3 x 5 repetitions

Integrate into team training


Methods (rehabilitation phase)
4 stage running/kicking programs
•
Some advanced rapidly
•
Others delayed by symptoms of high grade posterior thigh
pain, weakness and dysfunction
Decision to return to Full Training : Collaborative
Rehabilitation interval (RI)
RI= time from the injury to the return to full
training (measured in days)
2. Results and Discussion
Results of acute MRI images


31 acute clinical HAMSTRING strains were
imaged
Authors were not blinded to these MRI’s
Clinical Hamstring strains
“Posterior thigh pain”
N=31
MRI positive
N=17
55%
Double muscle
n=5
All involving BF as primary injury
Single muscle
N=12
Biceps femoris
N=8
MRI negative
N=14
45%
ST and SM
N=2 each
Recurrent hamstring injury

Of the 17 MRI positive cases (“hamstring
muscle strains”)

N= 6 recurred within same season!!

35% recurrence rate

Size of muscle strain injury (length &/or CSA%) did
NOT predict risk of recurrence
Recurrent hamstring injury

Of the 14 MRI negative cases

None recurred within same season!!

0 % recurrence rate
Statistical analysis
Statistician analyzed data

t-tests independent samples (dependent vs. independent
variables)

Two-way analysis of variance
Results: Statistical analysis
20
18
16
RI 14
(days) 12
10
8
6
4
2
0
MRI
Positive
MRI
positive(mean=20,
range 12-33 days )
MRI negative (mean
6.6, range 2-12)
MRI
Negative
MRI Diagnosis
MRI Positive

n=17

Mean RI=20.2 days

significantly longer RI
(p=0.001)
Results: Statistical analysis
30
25
RI
(days)
20
Length > 12cm
Length 7-12 cm
Length < 7cm
15
10
5
0
MRI Diagnosis
MRI & Prognosis

Length of intra-muscular
signal correlates best
with RI r=0.84,
p<0.001

CSA% & RI r=0.78
length (cm)
25
20
15
10
5
0

Size really does matter
0
10
20
30
Rehab Interval (days)
40
MRI negative cases

n=14

Mean RI= 6.6 days
(benign injury)
MRI negative cases
Hypotheses

MRI done too early

Strain injury too small to resolve

Other causes of “Posterior thigh pain”
Other causes of posterior thigh
pain

Somatic Referred pain


Lumbosacral spine
Pelvis
Other causes of posterior thigh
pain

Neuromeningeal
tethering




Nerve root (
“radiculopathy”)
Piriformis syndrome
Hamstring syndrome
Within HS muscles
Other causes of posterior thigh
pain

Intrinsic Muscle causes




Tender points
Trigger points
Adhesions/fibrosis/scarr
ing
Tendinopathy/bursitis
Other causes of posterior thigh
pain

“Not to be missed”







Avulsion Fractures
Complete rupture proximal
HS
Stress Fractures
Compartment syndromes
Tumours (benign and
malignant)
Infections (bone/soft
tissue)
Rheumatologic
CONCLUSIONS
Conclusions
MRI defines muscle strain injury objectively:
“probe beneath the surface of the skin”
Conclusions
Posterior Thigh Pain
MRI Positive
“Hamstring strain injury
MRI Negative
Numerous other DDx’s
Somatic referred
Neuromeningeal
Etc.
Conclusions
All 17 MRI positive cases of muscle strain injury
occurred about known muscle-tendon junctions
(This concurs with basic science studies)
Conclusions
The Biceps femoris was the most commonly
injured muscle (8 single, 5 “double” injuries)
Conclusions
Tenderness over the
posterior thigh does not
always = muscle strain
injury
Concept of “MRI
NEGATIVE” diagnosis
Conclusions
20
18
16
RI 14
(days) 12
10
8
6
4
2
0
MRI
Positive
MRI
positive(mean=20,
range 12-33 days )
MRI negative (mean
6.6, range 2-12)
MRI
Negative
MRI Diagnosis
Conclusions
30

Size ( LENGTH and
CSA%) of muscle
strain injury is also
predictive of RI
25
20
Length > 12cm
Length 7-12 cm
Length < 7cm
15
10
5
0
MRI Diagnosis
Conclusions
Indications for MRI
Acute MRI for elite
athletes
Soccer World Cup
2002
e.g. Posterior thigh pain 7 days before
Final
Can he play??
YES : if MRI negative
NO: if MRI positive
Conclusions
Indications for MRI
If no MRI available? Suspect MRI positive if
troubled by high grade posterior thigh pain in
rehabilitation
Thank-you
Questions?
MRI findings determine
type & pace of rehab



Positive vs Negative
 Entirely different
management
Length
 Predict return to play
 Set stages of rehab
Other markers
 Tendon involvement
 Fluid around sciatic
n.
REHABILITATION


Promote healing
 Regeneration > Scarring
Restore flexibility of injured region
 Prevent shortening




Common finding in retrospective studies
Restore strength of hamstring group
 Retraining of hip extension & knee flexion
 Prevent shortening of angle of peak torque
 More prone to damage with eccentric ex
 Due to injury or rehab or inherent
Running Re-Training
Correct contributing factors if possible
Brockett et al 2002
RUNNING RETRAINING



Formalised by G. Reid – Hockey background
Allows return to competitive sport prior to complete healing of
injury site
Involves:
 Running early – when stair walking pain-free
 Running is progressed in stages of speed increments
 Jog then Fartlek
 Running 90m intervals
EZ


5 stages till sprinting
Controlled sport specific drills prior to returning to training
Possible mechanism





Retraining of muscles responsible for the hip extensor & knee
flexor torque during running
BF-S & L, ST, SM, Glut, AM, Gastroc
Change in relative contribution of each muscle
Any change in recruitment yet to be determined
Sufficient slack in the system
 Inhibit the injured muscle
 Facilitate remaining muscles
Observations
1.


2.






Large single hamstring strains exhibit obvious inhibition
Lower resting tone on palpation
Poor recruitment during isometric contraction
Double hamstring muscle strains
14 BF & ST injuries – 9 recurred within rehab or within
12/12
64% recurrence rate – double the norm
May reflect an inability of the system to adequately
compensate for the injured muscle
Role of dual channel biofeedback
Early or later stages of rehab
Similar effect as suggested by Sherry & Best
Sherry & Best 2004



RCT of 2 programmes
24 grade 1-2 hamstring injuries
Stretch & Strength (11)


Stat bike, static & C-R stretches, isometric to conc to
ecc strength X’s with cuff wts, T/B & BW
Progressive Agility & Trunk Stabilisation (13)



JOSPT
Sidestepping, grapevines, fwd & bwd steps while
sidestepping, balance exercises, jogging on spot, trunk
stabilisation X’s
Progressive intensity
Both programmes involved sport practice when pain- free
Sherry & Best 2004


STST - mean RTS 37.4 days
PATS - mean RTS 22.2 days
JOSPT
(10-95, sd 27.6)
(10-35, sd 8.3)
p=0.2455

Recurrence rates





STST
PATS
54.5% at 2 wks, 70% at 1yr
0% at 2 wks, 7.7% at 1 yr
p=0.003
Allows regeneration > scar
Better prevention of atrophy
Better trunk stability, co-ordination or motor control
Contributing Factors

Strength L/R balance, H/Q balance
Burkett 1970, Yamamoto 1993, Orchard et al
1997,
Cameron et al 2003

Inadequate strength for function required



Eg. Running & bending or jumping
Determine mechanism
Specific Flexibility


Bennell et al 2003
Ankle Dorsiflexion < 10cm p=0.036
Hip Flexors – MTT > 0degs
p=0.051
Contributing Factors

Other injuries and Gluteal Function





Previous calf injury
Orchard 2001
Previous knee injury or osteitis pubis Verrall et al 2001
Altered biomechanical factors - inherent or due to injury
Ankle sprain ↓ glut function
Bullock-Saxton et al 1994
Poor lower limb motor control
Cameron et al 2003
Summary – Hammy Rehab

Diagnosis

Muscle strain or posterior thigh pain (PTP)


MRI & clinical testing
Extent of strain injury - MRI

Re-training Programme

Pre-disposing factors