Hamstring Group Strain
Mario Manjarrez Linares
Pathology and Evaluation of Orthopedic Injuries I
Dr. Sterner PhD, ATC
Medial Hamstring Group Strain
Mario Manjarrez Linares
Abstract
Objective: This case study will examine a grade 2, mid substance strain of the medial hamstring group in a 22-year-old male basketball athlete. This case study will explain the anatomy of the medial hamstring group, how this strain occurs, the physical examination that took place, diagnosis, and the treatment that ensues. Background: During a basketball game, the patient was chasing down an opposing player, and while sprinting he felt pain in the back of his left thigh. The patient was unable to walk or run, was evaluated by the ATC on site and ruled out of the game. There was no further medical treatment followed by the incident until the patient was evaluated at the AT facility 2 days later. Differential Diagnosis: Different diagnosis’s include hamstring tendon allusions, and proximal hamstring tendinopathies. Treatment: The patient will conduct rehab exercise, cryotherapy, and electric stimulation. Initially the patient will be taking anti inflammatory medications with food for 7 days. The rehab exercises will be conducted every other day during the week and in between those days the patient will do guided exercises in the pool or on the elliptical. Uniqueness: Hamstring strains account for 12–16% of all injuries in athletes with a re-injury rate reported as high as 22–34% Conclusion: This case study will examine all the details about this injury such as its history, the physical examination, diagnosis, treatment, and return to play process. The patient will be out for about 2-4 weeks if everything goes according to plan.
Keywords: Grade 2, medial hamstring group, strain, rehab exercises.
Personal Data
The athlete of my case study is a 22-year-old male on the Rowan’s basketball team. Basketball is a sport that requires explosive power, quickness, and balance among other skills. If athletes using these skills do not have proper technique or mechanics they have greater risks to injury on the lower extremities of their body such as the hamstring.
The hamstring muscle group is made up of the biceps femoris being the most lateral muscle, the semitendinosus, and the semimembranosus being the most medial muscle. The biceps femoris purpose is to flex the knee, externally rotate the tibia, externally rotate and extend the hip. It originates from the ischial tuberosity and inserts at the lateral aspect of the knee. The semitendinosus and semimembranosus both have the same function as they flex the knee, internally rotate the tibia, internally rotate and extend the hip. They both originate from the ischial tuberosity and insert to the medial aspects of the knee. The hamstring muscles also decrease the anterior shear forces that stress the ACL when the knee is flexed beyond 20 degrees.1 A hamstring strain is a common leg injury involving a tear in one or more of the hamstring muscles.2 Most muscle strains are usually a cause of dynamic overload or over stretching in the muscle. You're likely to get a hamstring strain during activities that involve a lot of running, jumping or sudden stopping and starting.3 Predisposing factors to this injury are poor flexibility, poor muscle coordination, muscle weakness, muscle imbalance, improper warmup, and/or fatigue. An external factor could be the playing surface meaning a wet slippery surface will put more strain on the hamstring due to slipping.2 Muscle strain severity gets graded from a scale of 1 to 3. Grade 1 meaning few fibers lacerated in the muscle, grade 2 meaning moderate damage to the muscle, and grade 3 meaning substantial damage such as a herniated muscle. Once a first muscle strain happens, there is a higher probability that it can reoccur in the future. It is essential all the proper steps are taken to recover and impede future injuries.
Chief Complaint
During a basketball game on November 14th, 2018 the patient was chasing down an opposing player who got a steal, and while sprinting he felt a sharp, sudden pain in the back of his left thigh. He described the pain as a sharp and “a rolling sensation” up the back of his leg with a pain scale of 7 out of 10. He stated that he was unable to run or walk without pain following the incident and was evaluated by the on site ATC. The patient was not entered back into the game. He did not seek further medical treatment following the incident. The patient was then evaluated by the athletic training staff on November 16th, 2018.
Physical Examination
When evaluated at the athletic training facility, the patient had an antalgic gait and swelling but no deformities. During palpations, the athlete had tenderness and palpable massive localized swelling along the mid-muscle belly of the semitendinosus and the semimembranosus. There was no palpable deformity or divot in the area. There was no tenderness at the origins and insertions of the hamstring muscles. All other palpations on the posterior aspect of the leg such as the biceps femoris, popliteal fossa, heads of the gastrocnemius, and the popliteal artery were within normal limits. Range of motion tests determined limited and painful during active knee flexion. All other active ranges of motion such as adduction, abduction, external rotation, internal rotation, hip extension, hip flexion, and knee extension were within normal limits. Passive knee extension and flexion were also within normal limits. There was no resistive range of motion tested. Manual testing indicated that hip extension was painful and graded a 2 out of 5. Knee flexion was also painful and grade a 2 out of 5. All other manual muscle testing such as external rotation, internal rotation, hip abduction, hip adduction, hip flexion, and knee extension were within normal limits. All neurological evaluations such as dermatomes, myotomes, distal capillary refill and the dorsalis pedis pulse were within normal limits. No special tests, radiological tests were conducted on the patient.
Results of Medical History
Imagining tests such as X-rays, ultrasounds, and Magnetic Resonance Images (MRI’s) frequently help confirm the clinicians' diagnosis. They’re not always needed unless there is incertitude of the pathology or if a muscle strain is severe enough that finding the exact location of the tear is necessary. An X-ray can show your doctor whether you have a hamstring tendon avulsion, which is when the injured tendon has pulled away a small piece of bone.4 MRI’s help give a better illustration of soft tissue like the hamstring muscle group to help determine the severity of the strain and the exact location. Fortunately for this patient his hamstring strain was not as severe, and he decided not to get any laboratory tests conducted.
Diagnosis
The athletic trainer’s evaluation gave him the impression that the patient suffered a grade 2, mid substance strain of the hamstring muscle group. This injury was acute and resulted from the patient making a sudden start to sprint down the court. His sharp pain in the back of his leg kept him from returning to the game. The patient had point tenderness and swelling along the muscle belly of the semitendinosus and semimembranosus which make up the hamstring. He had pain with active knee flexion, pain with hip extension/flexion during manual muscle testing which are the actions of the hamstring. Those were clear cut signs that lead to the conclusion of a grade 2 hamstring muscle strain. The severity of his injury lead to the estimation of the patient being out of participation 2 to 4 weeks.
Treatment and Clinical Course
Treatment for a hamstring strain is reliant of the location and the severity but overall it has a conservative treatment. Athletes with grade 2 strains usually take about 4-8 weeks to recover. Typically there are 3 phases one should go through for recovery. Like most injuries with initial inflammation, the objective is to reduce it and preserve the muscle so it can heal properly with time. Using the R.I.C.E method, and taking non steroidal anti- inflammatory medications to ease the pain should be the initial step towards recovery. Generally, a patient is considered ready to progress to the second phase of healing and treatment when he or she can tolerate a normal walking gait, an isometric contraction at 50% to 70% maximal, and a very low-speed jog without pain.5 The adjacent phase indicates the patient recovering the full range of motion of the muscle. As range of motion returns, the more challenging the exercises should be. Exercises should work with knee flexion hip extension as that is the role of the hamstring. Transcutaneous electrical nerve stimulation (TENS) can also be used to promote strength in the muscle and augment blow flow. Progression to the third phase of healing and treatment requires full strength and range of motion, with the ability to tolerate a backward jog at 50% maximal speed.5 To prepare the patient to return to their full capacity they must have specific exercises set that are sport specific. Such exercises that mimic the movements they would be executing during their sport. After the patient has returned to their sport, they should not cease their rehab exercises thinking they will be exceptional without them. Once the first muscle strain transpires the greater the risk a second muscle strain reoccurs in the future. The patient should proceed to strengthen their hamstring muscle, operate on mechanics and proper techniques to avoid re-injury. The patient should follow up with their clinician to secure everything is going according to plan.
The patient of my case study had a treatment plan set up for his specific needs. He would conduct rehab exercise, cryotherapy which is the use of cold temperatures to help heal, and electrical stimulation. The patient would be taking 800 mg of ibuprofen twice a day, orally with food for 7 days to control the pain. He will abide by the prescribed rehab plan as the return to play protocol found in the literature starting with stage 1. Rehab exercises would be Monday, Wednesday, and Friday. On Tuesday and Thursday the patient would do guided exercises in the pool or elliptical. Icing and electrical stimulation would follow. There were 3 goals set to assist the patient get back to activity. The patient’s decreased pain scale should go from 7 to 3 and no swelling should be present by November 23rd, 2018. His increased strength should go from 65% deficiency to less than 10% deficiency by December 12th, 2018. No progress was documented.
Criteria for Return
Return to play decision is critical for athletes because most of them are anxious to play but might not be prepared. Often, recommendations are vague, stating that athletes can be cleared to return to sport once full ROM, strength, and functional abilities (jumping, running, and cutting) can be performed without complaints of pain or stiffness.6 According to research these signs include no pain on palpation of the injured hamstring muscle, no difference in manual muscle testing between legs with no pain, and <10% deficit with passive flexibility tests to that of the uninjured leg with no pain. Isokinetic testing should also be performed during concentric and eccentric contraction. Isokinetic strength testing, measured at 60° and 180°, should result in a deficit of less than 5% compared with the injured side for clearance to return to sport.6 Hamstring to quad strength ratio should be less than 5% deficit bilaterally for the patient to return to play. A special test called the active hamstring test is also occasionally used to decide by the patient performing a straight leg raise as fast as they can without apprehension. If an athlete is nervous or dubious about the hamstring test, it is recommended they continue 1 to 2 weeks more of rehab and then repeat the test.
Discussion
Hamstring strains are one of the most common muscle strains on the body. It is important to create a proper rehab and treatment for this injury to prevent re-injury, changes in bio mechanics, and consistent weakness in the injured muscle. Depending if the injury is grade 1, or 2 and it doesn’t get diagnosed, it can become more severe by completely tearing the muscle. Misdiagnosis can also be a factor which can precede to a greater injury than when it started. Due to your sciatic nerve passing through the hamstring muscle group, a lower back injury, or some other injury that pinches the sciatic nerve can replicate the symptoms.2 According to a study of high school basketball players by the National Athletic Trainers' Association (NATA), 11% of injuries were hip and thigh which included hamstring strains. Hamstring strains account for 12–16% of all injuries in athletes with a re-injury rate reported as high as 22–34%.7
Conclusion
Hamstring strains injuries especially in quick movement sports like basketball aren’t bizarre. Depending on the severity graded 1 to 3, rehab for this injury isn’t complicated. Rest, pain medication, and strength exercises are the mainstream ways to help this injury. They are not to be taken freely so working on mechanics, stretching, muscle strength, and balance are preventions for hamstring strains. It is important to keep up on new information and research to prevent injuries from happening.