Jonny Sexton: Physiotherapy Injury Analysis

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 Jonny Sexton

Born: July 11, 1985 (age 27),

Height: 1.89 m

Weight: 92 kg

Country of birth: Dublin

Injury Update:

“Jonny’s scan revealed a grade two hamstring injury,” Ireland manager Mike Kearney said. “Progress has been good so far, but it’s too early to say when he will return to play.

What is a hamstring tear?

The hamstring muscle group is made up of three muscles (Semimembranosus, Bicep femoris and semitendinosus). The mechanism of injury is normally as the athlete is running or kicking. This is when the hamstrings are working eccentrically to decelerate the tibia. The moment just before the foot hits the ground (terminal swing phase of the gait cycle) is when the muscles are maximally activated and on end of range length, and thus at most risk of injury.

How are hamstring injuries graded?

Tears are graded on their severity.

Grade I consists of minor tears within the muscle.

Grade II is a partial tear in the muscle.

Grade III is a severe or complete rupture of the muscle.

How are hamstring injuries diagnosed?

  • Unless an avulsion fracture with bony fragment or apophyseal fracture is suspected, plain radiographs are of little use in the examination of an acute hamstring injury (Clanton and Coupe, 1998).
  • Ultrasound and MRI (MRI is thought to be more sensitive to subtle oedema).

Heidersccheit et al, 2010

What symptoms presentation would you expect from a grade II?

  • Gait will be affected.
  • Reduced performance.
  • May be associated with discomfort/pain during activity.
  • Palpation increases pain.
  • Hamstring strength test results in pain and reduced muscle power.
  • Reduced extension of the knee.
  • May notice swelling.

 

When will he be back? 

A study looking at rugby union players in 2006 found that:

  • The incidence of hamstring muscle injuries was 0.27 per 1000 player training hours and 5.6 per 1000 player match hours.
  • Injuries, on average, resulted in 17 days of lost time, with recurrent injuries (23%) significantly more severe (25 days lost) than new injuries (14 days lost).
  • Second-row forwards sustained the fewest (2.4 injuries/1000 player hours) and the least severe (7 days lost) match injuries.
  • Running activities accounted for 68% of hamstring muscle injuries, but injuries resulting from kicking were the most severe (36 days lost).
  • Players undertaking Nordic hamstring exercises in addition to conventional stretching and strengthening exercises had lower incidences and severities of injury during training and competition.

 

(Brooks et al, 2006)

 

Clinical Reasoning and return to play: Tissue Healing times

  • Bleeding (6-8 hours)
  • The Inflammatory phase ( 2-3 days- continuing to resolve over 2 weeks)
  • Proliferation Phase (2-3 days following injury to 2-3 weeks before reach its peak reactivity)
  • Remodelling (Recent evidence shows that this can begin 1-2 weeks post injury however 4-6 weeks is the general rule that a scar with enough tensile strength to begin withstanding higher loads is present.)
  • Treatment should be therefore targeted to optimise and complement the phase of healing.

(Watson, 2006)

 

Read more about these phases by an article written by Tim Watson, Electrotherapy Guru.

When can he return to sport?

  1. Full range of motion
  2. Strength, and functional abilities (eg, jumping, running, cutting) can be performed without complaints of pain or stiffness.
  3. When assessing strength, the athlete should be able to complete 4 consecutive pain-free repetitions of maximum effort manual strength test in each prone knee flexion position (90° and 15°).
  4. If possible, isokinetic strength testing should also be performed under both concentric and eccentric action conditions. Less than a 5% bilateral deficit should exist in the ratio of eccentric hamstring strength (30°/s) to concentric quadriceps strength (240°/s).
  5.  In addition, the knee flexion angle at which peak concentric knee flexion torque occurs should be similar between limbs.16,78
  6. Functional ability testing should incorporate sport-related movements specific to the athlete, with intensity and speed near maximum.

 

Listen to the following podcasts on advice regarding advising your athletes to return to sport:

Possible physiotherapy management of hamstring injuries

  • Initial RICE guidelines: Rest, Ice (10-15mins x 2-3 daily), Compression, and Elevation.
  • Avoid excessive stretch of the hamstring (can result in excessive scar formation).
  • If using crutches avoid ‘hanging leg in flexion’ as this increases tensile load on the tendons.
  • ROM should be guided by pain limits (ie do not push into pain in early stages)
  • NSAIDs are controversial and should be avoided if pain can be controlled with ice and activity modification alone.
  • Acupuncture
  • Electrotherapy:
  • Tens for pain relief (over nerve root) – This is not widely used to practice but is a possibility.
  • Ultrasound
  • Massage (not immediately following injury of if a haematoma is suspected)
  • Gentle stretches.
  • Static(isometric) strengthening.
  • Please read this brilliant article which takes you through appropriate exercises and the evidence behind them. (Heidersccheit et al, 2010)

 

Click here to view a comprehensive  hamstring rehab program. If any one who is reading this suspects they may have a hamstring tear be sure that you are guided by a physiotherapist to ensure correct diagnosis. A little knowledge can be a dangerous thing and these exercises will not be suitable for other conditions that can cause posterior leg pain. In particular it is important to rule out involvement of the back which may be causing neurogenic referral. Hamstring Rehabilitation and Prevention Protocol University of Delaware Sports and Orthopedic Clinic.

  

 

 References

Brooks JH, Fuller CW, Kemp SP, Reddin DB. Incidence, risk, and prevention of hamstring muscle injuries in professional rugby union. Am J Sports Med. 2006 Aug;34(8):1297-306. Epub 2006 Feb 21. PubMed PMID: 16493170.

Clanton TO, Coupe KJ. Hamstring strains in athletes: diagnosis and treatment. J Am Acad Orthop Surg. 1998;6:237–248.

Heiderscheit BC, Sherry MA, Silder A, Chumanov ES, Thelen DG. Hamstring strain injuries: recommendations for diagnosis, rehabilitation, and injury prevention. J Orthop Sports Phys Ther.2010;40:67–81. [PMC free article] [PubMed]

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