Introduction:
This case study presents a 21-year-old male Australian football rules football player with acute hamstrings strain of the right leg.
Hamstring muscle strains are one of the most frequent injuries in sports that involve sprinting (Orchard 2002; Thelen et al. 2005; Drezner 2003). Muscle strains are categorised based on the extent of muscle fibre damage: A first-degree strain is defined as an elongation of the musculotendinous units and results in a minimal loss of strength and a functional disability (Drezner 2003). A second-degree strain is characterized by a partial tear of the musculotendinous unit, and results in a well-defined loss of strength and more importantly a functional restriction. A third-degree strain symbolises a rupture of the musculotendinous unit and results in a severe functional disability (Drezner 2003).
According to Askling (2011),there are two characteristically different types of hamstrings strain, one which arises during high-speed running and primarily involves the biceps femoris long head, the second result from movements involving excessive elongation of the hamstrings, often involving the semimembranosus. The different types of injury decide rehabilitation time and the injuries implicating the central part of the tendon requires longer time to return to play (Drezner 2003; Brukner 2015; Askling 2011).
Advice considering rehabilitation and prognosis about healing time is often challenging due to the distinctive locations and the injury types (Askling 2011). The PRICE principle is a conventional treatment method after muscle injury to limit the amount of local bleeding, pain, inflammation and swelling (Drezner 2003).
SUBJECTIVE:
1. Social and family history:
- LF is a banker who plays Australian football on the weekends, he exercises 3-4 days a week and plays one match weekly.
- LF is a non-smoker, he eats healthy and drinks alcohol moderately.
- He lives in a flat share with two mates in the city. He is from Australia and moved to England in January 2017.
2. PMH
- Fracture of the 5th metatarsal (R) 2014 – healed
- Shoulder dislocation (L) 2016 – Returned to play in pre-season 2017.
- Right and Left ankle sprains – multiple times over the last 5 years, self-treated
- Hamstrings strain (R) x 2 in 2015 and in 2016
- No medicine use, no allergies, no heart condition.
- General health is good.
3. HPC
LF injured himself towards the end of the 3rd quarter of the match, injury mechanism was chasing down a ball and quickly decelerating to catch the ball. He immediately felt pain in the back of his right thigh and he had to leave the pitch. He could leave the pitch by himself with support of the physios.
There was swelling in the area that came on 15 minutes’ post injury.
The PRICE principles were used for the first 24 H as advised by the physios’ available pitch-side. The patient was seen in the clinic two days after injury.
BODY chart
24 H pattern – Injury occurred at 4.30 pm.
AM – Stiffness, pain while bending the knee, pain while getting out of bed, trouble sleeping first 3 days. VAS 7/10
PM – Pain while walking, painful with prolonged pressure from sitting. VAS 8/10Pain in the posterior thigh could be due to trigger points of the gluteal muscles or the hamstrings musculature or an impingement of the sciatic nerve. The past medical history of this patient warrants testing of the hamstring musculature. Previous hamstrings injuries are the strongest indicator of a new hamstrings injury and this situation he has had 2 previous strains of the hamstring on the same leg (Brukner 2015; Drezner 2003; Askling et al. 2013).1.
DISCUSSION AND CONCLUSION
In our case with this player we approached with the PRICE/POLICE principle with ice, rest, elevation and optimal loading to begin with.
After the first week, the swelling reduced and it was decided to start the L protocol as this has evidence that it may return the player more effectively back to sports. The player progressed quite quickly and we retested him at every visit to the physio, after three weeks it was decided to hand him over to the S&C coach since the tests from the Aspetar protocol(Thorborg et al. 2012) were all cleared.
When it comes to rehabilitation of Hamstring strain there is still a lack of support from prospective randomized research when it comes to current rehabilitation protocols (Sherry & Best 2004; Brukner 2015; Drezner 2003). The treatment goal of the medical professionals is to provide the athlete the same functional level as prior to the injury and therefore functional rehabilitation is of importance (Gabriel et al. 2017). The large variation in time needed to return to play makes an estimation of prognosis a challenge (Moen et al. 2014).
Carl Askling, developed the L protocol which mainly consists of eccentric exercises at a lengthened position of the hamstring musculature. This rehabilitation protocol has shown to be more efficient than a conventional treatment protocol in return to sport after injury (Brukner 2015; Askling et al. 2013).
Today, a number of researchers suggest a rehabilitation protocol based on strengthening and flexibility exercises that mainly include exercising with high loads at elongated muscle-tendon lengths before RTP (Gabriel et al. 2017; Askling et al. 2013; Brukner 2015; Thorborg et al. 2012).
In the H test by Askling, the player lies prone on a bench with his contralateral leg strapped to the bench, the involved leg is kept in full extension of the knee. The player is actively asked to perform a straight leg raise (SLR) as fast as possible and to the point where he/she feels insecure. This test has been proved reliable and applicable to athletes returning from injury (Askling et al. 2010).
The PRICE principle has been a traditional treatment after acute muscle injury to limit the amount of local bleeding, pain, inflammation and swelling (C. M. Bleakley et al. 2013; Bleakley, C., Glasgow, P., Phillips, N., Hanna, L., Callaghan, M., Davidson, G., Hopkins, T., Delahunt 2010; Drezner 2003; Gabriel et al. 2017). The POLICE/PRICE should not be used as a formula of a one size fits all, this approach rarely works (C. Bleakley et al. 2013; Bleakley, C., Glasgow, P., Phillips, N., Hanna, L., Callaghan, M., Davidson, G., Hopkins, T., Delahunt 2010)