Lower Limb. Hamstring Strains. Risk Factors. Dr. Peter Friis 27/04/15. 16% missed games AFL 6-15% injury in rugby 30% recurrent

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1 Lower Limb Dr. Peter Friis MB BS FACSP Sports Physician Hamstring Strains 16% missed games AFL 6-15% injury in rugby 30% recurrent Risk Factors Modifiable Warm up Fatigue Strength Flexibility L/Spine Pelvic tilt Technique Sport Non Age Previous strain Indigenous 1

2 Hamstring Strains Biceps femoris more prone to injury due to insertion and innervation. Biceps stretches more than the other two hamstring muscles. Hamstrings act as agonists of the ACL and acting eccentrically are more prone. Hamstrings cross two joints, rapid switching is a likely factor Pathological muscle contraction 2

3 Hamstring Assessment Askling L Exercises Rehabilitation and Functional Tests 3

4 MRI Grading and Prognosis Cross section > 50% equates to more than 6 weeks off. Increasing length of strain equates to increasing time off Best prognostic indicator is a normal scan.. Hamstring Tendinosis Ischial tuberosity Straight leg (bridge) localises it Lengthy rehab CSI??? Rest 4

5 Prevention Gluteals Eccentric training Loads Technique Physio 5

6 Eccentric training programme. Quads Strain 6

7 Physical examination should record degrees of knee flexion on both legs, firmness rating from 5 to 15 of injured muscle, and circumference of thigh at suprapatelllar border in both legs. The knee can be maintained in 120 of knee flexion with an elastic wrap or an adjustable range-of-motion brace set at 120 of flexion. The patient will need to use crutches, and should maintain this position of knee flexion for 24 hours. Nonsteroidal anti-inflammatory drugs (NSAIDs) should be administered for the first 48 to 72 hours only. Cryotherapy is associated with a significantly smaller hematoma between the ruptured myofibril stumps, less inflammation and less tissue necrosis, and a slightly accelerated early regeneration response. Corticosteroids have been shown to slow healing in contusion injuries by delaying the clearance of debris at the site of injury and prolonging the muscle regenerative process and recovery of muscle strength. Quads Strain? Bull eye lesion Small tendon in rectus femoris Rehab time significantly more 7

8 Myositis Ossificans The incidence of myositis ossificans (MO) after muscle contusion has been reported to be 9% to 17%. The precalcified stage can cause diagnostic problems, because MO is not always connected to a recent trauma and can resemble sarcoma Faint periosteal bone formation, occurs within 7 to 14 days, mature bone after 4-6 months. Compartment Syndrome Groin Pain 8

9 Athletic Pubalgia Multiple co-existing pathologies are often present which commonly include Posterior inguinal canal wall deficiency, Conjoint tendinopathy, Adductor tendinopathy, Osteitis pubis and Peripheral nerve entrapment. The mechanism of injury remains unclear but sports that involve either pivoting on a single leg (e.g. kicking) or a sudden change in direction at speed are most often associated with Athletic Pubalgia. 9

10 Pubalgia.chronic groin pain that presents with NO obvious hernia, and no clear-cut cause arising from the structures in the pubic region. Non-modifiable risk factors The most prominent risk factor for groin/hip injuries identified across the literature was: player history of a previous injury. deficits in physical conditioning, scar tissue formation, inadequate rehabilitation, reduced proprioception, altered movement patterns or premature early return to play after the initial injury Non-modifiable risk factors The second most prominent, non-modifiable risk factor was: Older Age 10

11 early maturing football players have a greater probability of sustaining a groin/hip injury Modifiable risk factors The most prominent modifiable risk factors were? BM and WHAM Decreased hip abduction ROM and total hip rotation ROM Adductor-to-Abductor strength ratio of less than 80%. 17 times more likely to sustain a groin injury Groin Tear 11

12 Adductor Squeeze Test 12

13 Where is the Hip? Don t forget the Hip! 13

14 Before asking the pa0ent to lie down, examine the hip and knee in the seated posi0on! Hip range of movement Hip range of movement 14

15 Femoral neck stress fractures Stress Fracture-NOF DO NOT MISS Female Runner, triathlete Vit D, Calcium menstrual Hx Hop pain, IR REFER 15

16 Stress Fracture Bone health Ca, pill, periods Vit D Biomechanics Program? rest days US/boots/crutches/ bisphosphonates Graded return 6 weeks Stress Fracture - Shaft Thigh pain Same risks 16

17 Stress Fracture - Shaft Thigh pain Same risks High loads Hang Test.. Prolonged rest Osteitis Pubis Uni or bilateral Vague Initially warms up Gradually deteriorates Tests Squeeze Adductor spasm Bone scan Flamingo view US other pathology 17

18 Tests MRI Osteitis Pubis Settle pain Address mechanics Graded return Monitored by squeeze Power and pain Lengthy Options are to grumble or resolve 18

19 If you choose grumble High maintenance physio Persist Range Eccentric strength Core work Straps/shorts Limit load Respond to soreness Adductor Tendinopathy Grading Grade 1 pain before and after training only Grade 2 pain during training but not affecting training Grade 3 pain that is limiting training Grade 4 pain during activities of daily living 19

20 Labral Tears of the Hip Pain with crossing legs Pain with end ranges of mo8on Pinching, catching, or gra8ng feeling inside hip Pain with combined flexion, adduc8on, and internal rota8on (knee across chest) Pain with combined flexion, abduc8on, and external rota8on (knee bent and res8ng out to side) Pain with resisted straight leg raise (raising leg against resistance) Hip Labral Tear Insidious pain, click or catch Point to groin Money Hip quadrant FABER Physio average CSI Surgery scope or osteotomy Femoro- Acetabular Impingement 20

21 Bursi8s 21

22 Paediatric Thigh and knee can be from hip DO NOT MISS Refer 22