Hamstring Injury

sprinting

What is a primary cause of acute hamstring injury

extreme stretching

What is a secondary cause of acute hamstring injury

- Proximal

- Mid belly

Where do acute hamstring strains typically occur (2 places)

- Proximal

- Distal

Where do chronic hamstring tendinopathies typically occur (2 places)

flexion

extension

SLR

Diagnosis made by palpation, pain/weakness with resisted knee _____ or hip ____, and pain with _____ test

1st degree

Name the degree hamstring tear

- micro-tear

- inflammation

- pain with contraction and stretch

- local pain

2nd degree

Name the degree hamstring tear

- macro-tear

- local pain and swelling followed by ecchymosis

- spasm

- pain with contraction and stretch

3rd degree

Name the degree hamstring tear

- complete tear

- palpable defect

- severe pain

- bruising

- loss of function and strength

review

Muscle Strains based on patient history profile

- Typically associated with dynamic overload to eccentric contractions

- Contributing factors include muscle weakness, older age (24y.o>), previous injury

- Usually can recall the injury which involves forceful stretching or contraction of muscle

- May hear or feel a pop followed by pain

- Most involved include quadriceps, hamstrings, hip flexors, adductors

review

Muscle Strains exam findings

- Inspection: Ecchymosis, swelling, deformity?

- AROM: limited ROM, pain with contraction and stretching

- PROM: pain with stretching muscle

- MMT: pain and/or weakness in muscle

- Palpation: Tenderness, possible defect

Violent contraction or tractioning of the muscle

what can cause an avulsion fracture

- ASIS

- AIIS

- lesser trochanter

- ischial tuberosity

what are common sites of avulsion fractures (4)

True

TRUE or FALSE: Avulsion fractures are more common in adolescent athletes.

signs/symptoms of avulsion fractures

- sharp pain at time of injury

- unwilling to move the extremity

- point tenderness along the bone

- muscle bulging away from the attachment

- swelling

biceps femoris (83%)

when the hamstring complex is injured…what specific muscle is most commonly injured

True

TRUE or FALSE: The Semimembranosus is most likely injured in low speed, stretching type injuries

True

TRUE or FALSE: The Long head of biceps femoris is most likely injured in sprinting-type injuries

Differential Diagnosis: HS Injury

- Sudden onset

- Pain with HS palpation

- HS strength loss (knee, hip)

- Pain with HS stretch: SLR/90-90

- Slump test negative: Could be positive in those with recurrent injury due to scar tissue.

HS injury: Referred Thigh Pain

- Sudden or gradual onset.

- No or minimal pain with HS palpation.

- Minimal or no HS strength loss.

- Slump frequently positive.

- Lumbar/pelvic exam abnormal and recreates symptoms.

True

TRUE or FALSE: Proximal strains compared to distal strains take longer to return to sport.

the area near the ischial tuberosity is more tendonous and therefore less vascularized compared to the central muscle belly.

Why is it that the closer the pain is to the ischial tuberosity the more likely it could take longer to return to play.

Trunk/hip

Acute HS Injury Management

- Relative rest and activity modification

- Avoid painful stretching or soft tissue therapy

- Gradual eccentric/lengthening exercises superior to conventional strengthening/stretching exercises

- ___/___ strengthening exercises

- Progressive return to sport (running program)

- Progression to sport specific tasks, assimilation into practices and games

review

Sub-acute/Chronic Management of HS injuries

- Progress strengthening activities and eccentric loading

- Sport specific rehab

1. Full HS strength without pain

2. Full range of motion without pain

3. No pain during rehab exercises

4. Askling H-test negative

Proposed Criteria for Return to Sport post HS injury

at the end of rehab

when is the H-test performed

- Pain, strength, and flexibility should be normal.

- Active SLR as fast as possible.

- Any reported pain or insecurity = extend rehab.

- Retest in 3-5 days.

key points about the H-test

Gradual onset

what is the onset of Proximal Hamstring Insertional Tendinopathy

Proximal Hamstring Insertional Tendinopathy

- Usually due to rapid increase in load on the HS in greater degrees of hip flexion (running up hill, running with forward trunk lean, deep squats, lunges, or deadlifts).

- Etiology: tendon compression and tension with loading/stretching HS in hip flexion.

flexion

Exam findings for Proximal Hamstring Insertional Tendinopathy

- Patient reports pain in buttock region around area of ischial tuberosity.

- pain with passive end range hip ____

- tenderness over ischial tuberosity and HS origin

- pain with deep squat, lunge, or single leg bridge.

- Other pathologies may co-exist

- Rule out lumbar spine

- Rule out intra-articular or other extra-articular (deep gluteal syndrome) of the hip.

- Rule out red flags: cancer, fractures, GI, urogenital.

- Sciatic nerve may be involved and produce neurogenic type symptoms.

Differential diagnosis for Proximal Hamstring Insertional Tendinopathy (review)

- Decrease activities with loaded hip flexion (hill running, squats, lunges, deadlifts).

- Stop stretching

what does activity modification for Proximal Hamstring Insertional Tendinopathy Management entail

flexion

flexion

Staged rehab for Proximal Hamstring Insertional Tendinopathy Management

1. HS Isometrics with hip in neutral

2. HS Isotonics in minimal hip _____

3. HS isotonics with hip in greater degrees of _____

4. Plyometrics and return to sport

Distal HS tendinopathy

- Can occur at medial or lateral HS insertion.

- Often due to new activity or rapid increase in activity involving repetitive eccentric HS contraction

flexion

Exam findings for Distal HS tendinopathy

- distal HS tender to palpation

- pain with resisted knee _____ (may need to bias towards medial or lateral HS).

- Relative rest to calm things down

- Isometrics progressing to isotonics

- Gradual return to activity

what does treatment for Distal HS tendinopathy look like

- Muscle strains diagnosed using selective tissue tensioning.

- Location of injury helps with prognosis.

- Relative rest + early lengthening exercises

- Progressive strengthening and return to sport

key points about acute HS strains (review)

flexion

flexion

Key points about Chronic HS tendinopathy

- Activity modification (avoid loading in extreme hip ______)

- Gradual loading starting with hip in neutral and progressing towards greater degrees of hip ______.