Case Study: Hamstring Grade II tear

Case Study: Hamstring Grade II Tear

The following case study gives you an idea of what treatments may be considered for this patient. This is a brief overview. Any CPD or case study for university would require much more depth and must be evidence based and demonstrate clear clinical reasoning. Many examples of these can be found through Pubmed and these should (alongside university guidelines)  be used as your outline for graded work.

Introduction

A 24 year old man presented with a one week history of right posterior thigh pain following a football injury at the weekend. He reports that he felt severe pain and a ‘twange/pop’ sensation after kicking a ball. He reports no swelling but has noticed a small bruise in the centre of the posterior thigh. He describes that symptoms are worse with activity and in the mornings he notices the muscles are tight but ease with gentle movement and stretches. He reports no history of back pain and no paraesthesia or pins and needles in the lower limbs. His GP advised NSAIDs to manage pain and advised resting from football for one week. There was no other past medical history and the patient had no history of previous hamstring tears.

Clinical Impression

The objective findings of the assessment fitted with a Grade II hamstring tear. The patient experienced tenderness on palpation of the right mid bicep femoris muscle 1cm superior to a small bruise (1cm x 1cm). Straight leg raise was limited to 40 degrees before onset of symptoms. Additional cervical spine flexion did not change symptoms in the leg during the straight leg raise suggested that there was not a neural component.

The patient demonstrated good ROM of the lumbar spine however flexion was limited due to ‘pain in the hamstring.’ There was reduced muscle strength of the right hamstring MMT 4/5 with knee flexion 90 degrees and MMT 4/5 with knee flexion 15 degrees. The patient had full AROM of the right knee however hyperextension elicited pain in the hamstring. On gait analysis he demonstrated reduced stride length on the right and reduced stance phase on the left.

No avulsion fracture was suspected and due to the available resources the patient was not immediately sent for MRI (Heidersccheit et al, 2010). Instead tissue healing times (Watson, 2006) were explained and the usual course of this type of injury.

Treatment Goals

  • Treatment goals were discussed and formulated with the patient.
  • Reduction of posterior thigh pain.
  • Restore optimal ROM and strength of the hamstrings.
  • Return to competitive football with 36 days ( Average duration of time lost in injuries resulting from kicking, Brooks et al, 2006)

 Treatment Plan “Tool box”

Hamstring injuries are not just prevalent in rugby and football. Dancers and kick boxers are also at risk dur to the excessive strain on the hamstring.

  • Initial PRICE guidelines: Protect, Rest, Ice for pain relief only, 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.
  • Taping
  • Static(isometric) strengthening.

Treatment 1

  1. The patient was screened for contra indications for treatments
  2. Patient was educated on the condition, tissue healing times and then given a copy of:  Hamstring Rehabilitation and Prevention Protocol University of Delaware Sports and Orthopedic Clinic. and Heidersccheit et al, 2010 hamstring protocol.
  3. Ultrasound was applied to the tender area in the mid bicep femoris. Please see Tim Watson, electrotherapy for further information on settings to choose.
  4. Home exercises program(HEP) : The patient was advised to begin phase 1 of the Heidersccheit et al, 2010 protocol. Patient was advised to reduce repetitions if experiencing increased symptoms/ pain.
  5. Advised ice for pain relief if needed.

P/ Review 1/52

Treatment 2

  1. The patient reported good progress and was able to complete more repetitions of the exercises from the protocol.
  2. Ultrasound was applied to the tender area in the mid bicep femoris. Please see Tim Watson, electrotherapy for further information on settings to choose.
  3. Home exercises program(HEP) : The patient was advised to continue phase 1 of the Heidersccheit et al, 2010 protocol. Patient was advised to increase repetitions gradually and reduce again if experiencing increased symptoms/ pain.
  4. Deep transverse frictions were applied to the point of tenderness on the bicep femoris x 30 sec x 3.
  5. Clinical massage was applied to the right hamstrings to encourage blood supply, reduce myofascial trigger points and mobilise the fascia. The patient was unable to move to phase II because he was still unable to complete a pain free isometric contraction against submaximal (50-70%) resistance with prone knee flexion 90 degrees.

Treatment 3

  1. The patient reported good progress and feels he is ready to move on to phase II.
  2. The criteria to move to phase II is as follows:
    1. Normal walking stride without pain
    2. Very low speed jog without pain
    3. Pain-free isometric contraction against sub-maximal (50-70%) resistance during prone knee flexion (90°) manual strength test.
  3. Following a test of these 3 things the patient was deemed fit to move on to phase II.
  4. Ultrasound was applied to the tender area in the mid bicep femoris. Please see Tim Watson, electrotherapy for further information on settings to choose.
  5. Home exercises program(HEP) : The patient was advised to move phase II of the Heidersccheit et al, 2010 protocol. Patient was advised to increase repetitions gradually and reduce again if experiencing increased symptoms/ pain.
  6. Deep transverse frictions were applied to the point of tenderness on the bicep femoris x 30 sec x 3.
  7. Clinical massage was applied to the right hamstrings to encourage blood supply, reduce myofascial trigger points and mobilise the fascia.

Treatment 4

  1. The patient reported good progress and feels he is ready to move on to phase II.
  2. The criteria to move to phase II is as follows:
    1. Full strength (5/5) without pain during prone knee flexion (90°) manual strength test
    2. Pain-free forward and backward jog, moderate intensity
  3. Following a test of these the patient was experiencing pain with maximal strength testing so advised to continue phase II for a further week..
  4. Ultrasound was applied to the tender area in the mid bicep femoris. Please see Tim Watson, electrotherapy for further information on settings to choose.
  5. Home exercises program(HEP) : The patient was advised to continue phase II of the Heidersccheit et al, 2010 protocol. Patient was advised to increase repetitions gradually and reduce again if experiencing increased symptoms/ pain.
  6. Deep transverse frictions were applied to the point of tenderness on the bicep femoris x 30 sec x 3.
  7. Clinical massage was applied to the right hamstrings to encourage blood supply, reduce myofascial trigger points and mobilise the fascia.

Treatment 5

  1. The patient reported good progress and feels he is ready to move on to phase II.
  2. The patient was able to demonstrate good muscle strength of the right hamstring 5/5.
  3. There was now minimal pain on palpation of the hamstring.
  4. Home exercises program(HEP) : The patient was advised to continue phase III of the Heidersccheit et al, 2010 protocol. Patient was advised to increase repetitions gradually and reduce again if experiencing increased symptoms/ pain.
  5. Exercises were demonstrated and completed with mild tenderness.
  6. The patient was advised to continue to follow the protocol before returning to sport which

Conclusions

  • The patient returned to sport at approximately 8 weeks following the injury. This is longer than the average ‘kicking’ hamstring tear within rugby union injury reports (Brooks et al, 2006), which averages 36 days lost. This was perhaps because compliance with daily exercises was limited due to the patients working life and difficulty getting to the gym to use a bike.
  • Unfortunately with NHS  demands, physiotherapists often are unable to see the patient through to return to sport however by providing this clear program physiotherapists can be a vital tool in assessing if the patient is ready for progression and minimising compensations.
  • The addition program was given to help protect the player from future injuries. It is important to highlight that hamstring re-injury rate is larger than those who have already experienced a hamstring tear therefore it is important to continue exercises within their training plan to prevent future problems.

References

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

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.

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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