Hamstring TearHamstring TearDr Riaan BarnardDr Riaan BarnardMB,ChBMB,ChBBSc HonsBSc HonsM Sport Med (3’rd year)M Sport Med (3’rd year)

Biggest set of “Hams” in SA !Biggest set of “Hams” in SA !

Case HistoryCase History

• Mr Chris Howes, Triathlon Athlete, aged Mr Chris Howes, Triathlon Athlete, aged 45, tried a dry Slalom take-off on 22/12/1045, tried a dry Slalom take-off on 22/12/10

• Slipped, ended in “splits”, felt sharp pain Slipped, ended in “splits”, felt sharp pain mid-upper section L hamstring, feeling of mid-upper section L hamstring, feeling of “something shearing off”“something shearing off”

• Immediately couldn’t walk – limped backImmediately couldn’t walk – limped back• Took some NSAIDs, ice & pain meds, Took some NSAIDs, ice & pain meds,

Kinesio Tape and “hoppled along” rest of Kinesio Tape and “hoppled along” rest of vacationvacation

• Saw Dr v Hagen on 3/1/11 for sonarSaw Dr v Hagen on 3/1/11 for sonar

Sonar Results ??Sonar Results ??

• Showed very large, hypoechoic area of Showed very large, hypoechoic area of 5,5 x 4,5cm in mid-upper Biceps Femoris 5,5 x 4,5cm in mid-upper Biceps Femoris section Lsection L

• Diagnoses of Grade II – III Hamstring Tear Diagnoses of Grade II – III Hamstring Tear was madewas made

• Previous History:Previous History:

• No previous hamstring tears / injuryNo previous hamstring tears / injury

• Lower back injury last 6/12 – saw Chiro Lower back injury last 6/12 – saw Chiro regularly for manipulationsregularly for manipulations

Clinical ExaminationClinical Examination

• Large bruised area whole hamstring area Large bruised area whole hamstring area with extravasation into popliteal fossawith extravasation into popliteal fossa

• TP’s palpable surrounding area & GluteusTP’s palpable surrounding area & Gluteus

• Ext knee - resulting pain in hamstring Ext knee - resulting pain in hamstring areaarea

• Hamstring muscle stretch test positiveHamstring muscle stretch test positive

• Eccentric hamstring contraction pain ++Eccentric hamstring contraction pain ++

• No neurological deficit / neg Slump testNo neurological deficit / neg Slump test

Diff Diagnoses / Spec Diff Diagnoses / Spec InvestigationsInvestigations

• Grade II Hamstring Tear – Biceps Femoris Grade II Hamstring Tear – Biceps Femoris + possible Semimembranosus+ possible Semimembranosus

• Caused by sudden forceful eccentric Caused by sudden forceful eccentric stretching, possible predisposing factor stretching, possible predisposing factor large hamstring muscle, not warmed up large hamstring muscle, not warmed up by stretching, possible stiffness due to by stretching, possible stiffness due to contributing back problem?contributing back problem?

• Serial Sonars were done with each Serial Sonars were done with each subsequent PRP injection follow-upssubsequent PRP injection follow-ups

3-Stage Summary3-Stage Summary

• Personal / Psychological:Personal / Psychological:

Not being able to compete in the 2011 Iron Not being able to compete in the 2011 Iron

Man SeriesMan Series

Social / Contextual:Social / Contextual:

Felt he was letting his fiancé down, as he Felt he was letting his fiancé down, as he

is her training partner for Iron Manis her training partner for Iron Man

Plan & ProgressionPlan & Progression

• Consulted me on 5/1 for PRP injection. Sonar directed Consulted me on 5/1 for PRP injection. Sonar directed 5cc volume injected into hypoechoic area.5cc volume injected into hypoechoic area.

• Initiated straight leg hamstring stretches + active knee-Initiated straight leg hamstring stretches + active knee-extensions to point of pain. Ice and Tramacet prn – no extensions to point of pain. Ice and Tramacet prn – no NSAIDs !NSAIDs !

• Sent to Chiro for Lumbo-sacral hypo-mobile segment to Sent to Chiro for Lumbo-sacral hypo-mobile segment to be manipulated, as well as soft tissue treatment, dry be manipulated, as well as soft tissue treatment, dry needling for surrounding TPsneedling for surrounding TPs

• On 8+9/1 swimming slowly in pool + continued On 8+9/1 swimming slowly in pool + continued stretching & strengthening exercisesstretching & strengthening exercises

• On 14/1 did slow 2-3km jog the morning – pain free. On 14/1 did slow 2-3km jog the morning – pain free. Later that afternoon PRP nr 2. Hypoechoic area shrunk Later that afternoon PRP nr 2. Hypoechoic area shrunk to 3,5 x 2,5cm with new tissue formation visibleto 3,5 x 2,5cm with new tissue formation visible

Progression Progression continued…continued…

• On 15/1 did slow 100km cycling race – pain freeOn 15/1 did slow 100km cycling race – pain free• On 21/1 did 10km run – pain freeOn 21/1 did 10km run – pain free• Last PRP nr 3 injected on 26/1 – hypoechoic area Last PRP nr 3 injected on 26/1 – hypoechoic area

shrunk to 1,5 x 0,5 cmshrunk to 1,5 x 0,5 cm• Did Half-Iron Man in East Londen on 29/1. Strapped the Did Half-Iron Man in East Londen on 29/1. Strapped the

leg with Kinesio Tape and finished the race in better leg with Kinesio Tape and finished the race in better time than previous year ! Qualified for Iron Man April time than previous year ! Qualified for Iron Man April 20112011

• What assisted a lot in this case, was the athlete’s What assisted a lot in this case, was the athlete’s background on rehab of injuries. It was thus easy to background on rehab of injuries. It was thus easy to give him a copy of B&K pg 453 – Progressive Running give him a copy of B&K pg 453 – Progressive Running Protocol and the Criteria for RTS to be followedProtocol and the Criteria for RTS to be followed

Sonar guided PRP injectionsSonar guided PRP injections

Continued…Continued…

DiscussionDiscussion• Well described chapter in B&K pg 443-453Well described chapter in B&K pg 443-453

Epidemiology & Biomechanics of Injury :Epidemiology & Biomechanics of Injury :• Sprinters, hurdlers, long jumpers, football Sprinters, hurdlers, long jumpers, football

players and dancersplayers and dancers• Most common in sports high-speed running & Most common in sports high-speed running &

kicking – biceps femoris most common injury. kicking – biceps femoris most common injury. Athletes immediately stop with injuryAthletes immediately stop with injury

• In dancers slow stretch movement at the end of In dancers slow stretch movement at the end of range of movement (front & side splits) causes range of movement (front & side splits) causes 87% cases of prox tendon of 87% cases of prox tendon of semimembranosus. Dancers are often able to semimembranosus. Dancers are often able to continue dancing immediately after the injurycontinue dancing immediately after the injury

Predisposing Factors to InjuryPredisposing Factors to Injury

• Intrinsic Factors:Intrinsic Factors: Extrinsic Factors:Extrinsic Factors:

These include These include - Age - Warm-upAge - Warm-up- Previous Injury - FatiguePrevious Injury - Fatigue- Race - Fitness LevelRace - Fitness Level- Flexibility - Training ModalitiesFlexibility - Training Modalities- StrengthStrength- NeuromyofascialNeuromyofascial- Lumbopelvic StabilityLumbopelvic Stability- Joint DysfunctionJoint Dysfunction

Review Article: Mann et alReview Article: Mann et alThree groups of Hamstring Injuries:Three groups of Hamstring Injuries:

1.1. Proximal Proximal affecting common hamstring origin. affecting common hamstring origin. Divided into 3 categories:Divided into 3 categories:

- - Tendon injuryTendon injury with full detachment ischium, with full detachment ischium, found mostly in adultsfound mostly in adults

- - Partial tearsPartial tears & overuse micro traumatic & overuse micro traumatic tendon tears in adults & childrentendon tears in adults & children

- - Apophyseial overuseApophyseial overuse or acute damage with or acute damage with or without avulsion, mainly in childrenor without avulsion, mainly in children

2.2. Central Central hamstring injuries of muscle bellieshamstring injuries of muscle bellies

3.3. Distal Distal injuries affecting distal tendon or injuries affecting distal tendon or tendon insertionstendon insertions

Proximal InjuriesProximal Injuries• Proximity of sciatic nerve important – oedema & Proximity of sciatic nerve important – oedema &

inflammation lead to irritation, leading to false inflammation lead to irritation, leading to false impression of spinal nerve root compressionimpression of spinal nerve root compression

• Thus strong argument exists to reinsert Thus strong argument exists to reinsert disrupted prox hamstring tendon to origin on disrupted prox hamstring tendon to origin on ischium, both to regain function and preserve ischium, both to regain function and preserve sciatic nerve from later damagesciatic nerve from later damage

• 3 Stages of Apophyseal damage: 3 Stages of Apophyseal damage: apophysiolysis, avulsion and non-united apophysiolysis, avulsion and non-united avulsion fractureavulsion fracture

• Union in widely displaced avulsion require 1-2 Union in widely displaced avulsion require 1-2 yrs. Avulsion > 2cm has common non-union and yrs. Avulsion > 2cm has common non-union and surgical repair should be consideredsurgical repair should be considered

Central Hamstring InjuriesCentral Hamstring Injuries

• Theories:Theories:

- Type II muscle fibers responsible for explosive - Type II muscle fibers responsible for explosive force, more abundant in hamstrings than quadsforce, more abundant in hamstrings than quads

- All hamstring muscles innervated by tibial - All hamstring muscles innervated by tibial branch of sciatic nerve, except short head branch of sciatic nerve, except short head biceps innervated by peroneal branch of sciatic biceps innervated by peroneal branch of sciatic nerve – leads to forceful, uncoordinated nerve – leads to forceful, uncoordinated contractions, or simultaneous contraction of contractions, or simultaneous contraction of hamstrings and quadshamstrings and quads

Brunet & Hontas’ ClassificationBrunet & Hontas’ Classification

• Grade I:Grade I: Small area, little haemorrhage and no structural Small area, little haemorrhage and no structural

damagedamage• Grade II:Grade II: Felt “pop” or tear, immediate function loss, Felt “pop” or tear, immediate function loss,

swelling, palpable painful mass, definitive swelling, palpable painful mass, definitive structural damagestructural damage

• Grade III:Grade III: Complete tear, mass of palpable muscle, mass Complete tear, mass of palpable muscle, mass

retracts on muscle activation, defect seen best retracts on muscle activation, defect seen best at 2-3 weeks at 2-3 weeks

Distal InjuriesDistal Injuries

• More frequently the tear takes place in the More frequently the tear takes place in the distal insertion of the Biceps Femorisdistal insertion of the Biceps Femoris

• Semimembranosus distal tendon is rarely Semimembranosus distal tendon is rarely rupturedruptured

• Most full ruptures should be repaired at an Most full ruptures should be repaired at an early stage, followed by 5 weeks of cast early stage, followed by 5 weeks of cast immobilisationimmobilisation

• Semitendinoses tears should be left alone and Semitendinoses tears should be left alone and not surgically repaired – little morbidity is not surgically repaired – little morbidity is caused by its absence when used as graft in caused by its absence when used as graft in ACL repairsACL repairs

Take Home Message / Learning Take Home Message / Learning ExperienceExperience

• Using PRP sonar guided injections Using PRP sonar guided injections work very well in acute muscle tears of work very well in acute muscle tears of the hamstring muscles and the hamstring muscles and dramatically reduces return-to-play dramatically reduces return-to-play time !!time !!

ReferencesReferences

1.1. Brukner, P; Khan, K. Clinical Sports Medicine, Brukner, P; Khan, K. Clinical Sports Medicine, Third Edition. 2008. pg 443Third Edition. 2008. pg 443

2.2. Deleget, A. Overview of Thigh Injuries in Dance. Deleget, A. Overview of Thigh Injuries in Dance. Journal of Dance Medicine & Science. 2010, vol Journal of Dance Medicine & Science. 2010, vol 14(3), pg 97-102. 14(3), pg 97-102.

3.3. Koulouris, G; Connell, D. Imaging of Hamstring Koulouris, G; Connell, D. Imaging of Hamstring Injuries: Therapeutic Implications. Eur Radiol Injuries: Therapeutic Implications. Eur Radiol (2006) 16: 1478-1487(2006) 16: 1478-1487

4.4. Mann, G; Shabat, S; Friedman, A; et al. Hamstring Mann, G; Shabat, S; Friedman, A; et al. Hamstring Injuries. Orthopedics/ORTHOsupersite.comInjuries. Orthopedics/ORTHOsupersite.com

5.5. Wehling, P; Moser, C; Frisbie, D; et al. Autologous Wehling, P; Moser, C; Frisbie, D; et al. Autologous Conditioned Serum in the Treatment of Orthopedic Conditioned Serum in the Treatment of Orthopedic Disease. Biodrugs 2007: 21(5): 323-332Disease. Biodrugs 2007: 21(5): 323-332