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HAMSTRING INJURY

A CLINICAL DIAGNOSIS

 

– Written by Johannes L Tol, Qatar and Arnlaug Wangensteen, Norway and Qatar

 

 

INTRODUCTION

An accurate diagnosis is essential to ensure that the injured athlete receives appropriate treatment and rehabilitation, and correct information related to the prognosis1. In most cases the diagnosis is straightforward and already put forward by the athlete himself. However, these ‘simple’ cases might not be as simple as initially expected.

The diagnosis and prognosis for time to return to sport (RTS) after acute hamstring injuries are mainly based on a comprehen-sive clinical examination2–7. In cases where the clinical appearance and severity is unclear, determining the optimal treatment can be difficult. Additional radiological imaging is often used to confirm the diagnosis and to provide information about the severity and the location of the injury. This information can provide guidance for further treatment8. Complete ruptures or avulsion of the tendinous insertions (with or without a bony fragment) usually have a worse prognosis and in some cases, surgery may be warranted9,10. Therefore, an important goal of these initial investigations is to identify those infrequent yet severe cases where surgical treatment might be indicated9.

 

CLINICAL EXAMINATIONS

The initial clinical examination starts with a comprehensive medical history taking followed by specific physical asses-sments and tests2,3,5, preferably performed within the first days after injury5,11–15. An early initial clinical diagnosis is essential to initiate optimal loading and rehabilitation after the injury3,4,16.

 

PATIENT HISTORY

Patient history is considered the foun-dation of the diagnosis. In fact, it might by itself provide an accurate diagnosis in many cases. Even in the acute situation on the field, the athlete will tell you in that he has sustained a hamstring injury and, in the majority of the cases, is unable to continue. 

The patient history provides an important overall picture of the injury situation and a preliminary impression of the injury severity. In order to get a good assessment of the injury situation, the clinician gathers information about:

  1. the injury mechanism (i.e. high-speed running or more slow stretching related type of injury)5,17,
  2. whether there was a sudden onset with sharp/severe pain in the posterior thigh,
  3. if the athlete was forced to stop immediately, and
  4. an audible ‘pop’.

This can aid the clinician in confirming the diagnosis, and might give some indication about severity6,7. Commonly, subjective pain at the time of injury is measured with a visual analogue scale (VAS) or a numeric rating scale and higher scores have been associated with longer time to full RTS18.

 

INJURY MECHANISM

Injury type and injury situation / mechanism

The evidence regarding the actual injury mechanism related to acute hamstring injuries is limited, and the subject of much debate. The majority of hamstring injuries are reported to occur during high-speed running when the athlete is accelerating or running at (or close to) maximal speed13,17,19–22 typical in sports like football20,21, rugby23, and athletics13,24. Another hamstring injury type is referred to as the slow-speed stretching type of injury17, occurring during slow movements with excessive stretch and large joint excursions including hyper-flexion of the hip combined with knee extension, typically seen in dancers14,25.Other injury situations, such as kicking, high kicking, glide tackling, twisting and cuttings are also reported17,19. Hip hyper-flexion combined with knee extension is commonly seen in patients sustaining a proximal hamstring tendon avulsion injury. Recently, an alternative injury mechanism was suggested in a smaller case series (n=3), involving a substantial hip abduction component (flexion-abduction injury mechanism)26. The biceps femoris long head is reported to be the most frequently injured muscle21,27–29.

Biomechanical studies show that the hamstrings are most active from the mid-swing until the terminal phase of the stride cycle during running and sprinting30–34.It actively lengthens during the terminal swing phase with a combination of hip flexion and knee extension, absorbing energy from the decelerating limb in preparation for foot contact6.

Muscle strain injuries during high-speed running are thought to occur during eccentric muscle contractions when the muscles are lengthened while producing forces35,36. Other biomechanical studies37–41, including two independent case reports with video footage of hamstring injuries occurring during high-speed running38,39,41, have hypothesised that hamstring injuries most likely occurs during this terminal swing phase of high-speed running. During this terminal swing phase, the peak hamstring musculotendinous stretch seems to occur, and is significantly greater for biceps femoris (probably because of a shorter knee extension moment arm)30. However, controversies exist and the early stance phase has also been suggested as highest risk period during the gait cycle, since the hamstring muscles are also working against potentially large opposing forces42.

 

RED FLAGS DURING HISTORY TAKING - DO NOT MISS COMPLETE AVULSIONS

To rule out more severe injuries, consider a combination of signs and symptoms that include excessive pain located at the tendons insertions (proximally at the ischial tuberosity or distally); and typical acute injury situations with a mechanism of extreme hip flexion with the knee extended (e.g. sagittal split or falling forwards with the upper body while the leg is fixated to the ground). Combined with an audible ‘pop’, this should raise concern for a possible total rupture of the proximal tendon(s), and further radiological investigations are indicated10. Less common in football, the type of sport may lead to a suspicion of a complete rupture; for example, water skiers are at a high risk of avulsion injuries8,43.

Red flags on history taking include pain on sitting, severe loss of function and force on isometric contraction, as well as difficulty when walking. Extensive bruising after some days are indicative of a complete avulsion. However, absence of these signs do not completely exclude complete avulsions and without the need to flag every patient, clinicians should be aware of the risk that these injuries might be missed (see Box 1)44.

 

PHYSICAL ASSESSMENT

The physical assessment starts with observation of gait pattern and function, followed by inspection of the injured area, palpation of the hamstring complex, active and passive flexibility and range of motion (ROM) testing of the hip and knee joint, isometric pain provocation, and muscle strength testing2,5,6,11. Pain provocation tests and deficits compared to the contralateral uninjured leg are usually registered5. A VAS or a numeric rating scale is used to quantify the athlete’s subjective pain5,45 during flexibility and strength testing. To measure side-to-side differences in ROM and muscle strength, objective assessment tests use goniometers or inclinometers and hand-held dynamometers5,11,15,46. Hamstring flexibility of the injured leg is usually reduced compared to the uninjured leg after acute hamstring injury5,6,11,47, and commonly examined in conjunction with other assessments to establish a diagnosis.

The active and passive straight leg raise tests and active and passive knee extension tests are most commonly referred to in the literature following hamstring injuries5,11,15,48–50. In studies among healthy participants, these flexibility tests demonstrate moderate to good reliability49. But since these tests are usually limited by pain and discomfort in an acutely injured athlete, reliability results from healthy participants may not be directly applicable to injured athletes. To date, only one study has reported on the reliability of flexibility testing in athletes with acute hamstring injuries50, showing good intertester reliability for the active and passive knee extension tests. Pain with isometric contraction and hamstring muscle strength deficits compared to the uninjured leg is commonly present initially after an acute hamstring injury5,6,51. Just recently, a meta-analysis reported that lower isometric strength was found  in the first week post-injury, but did not persist beyond seven days51. However, there are few studies that have reported strength deficits immediately after the injury, as the focus in the literature mainly has been directed towards isokinetic and eccentric strength deficits at or after RTS51. Additional neurological and diagnostic tests may also be performed to rule out other possible sources of posterior thigh pain6,52,53.

In adolescents reporting an acute onset injury, the possibility of an apophyseal avulsion fracture must be excluded54,55. The cartilaginous growth plates at the apophyses of adolescents are more vulnerable than other parts of the musculotendinous unit, and are the first to fail, resulting in avulsion fractures. The pain is typically more severe during activity and decreases with rest, and clinical examination reveals local tenderness, reduced ROM and swelling56. Radiography (X-ray) of the pelvis in at least two planes should be performed in athletes with typical clinical findings and a relevant history of trauma54.

 

POST RETURN TO SPORT: CLINICAL FOLLOW-UP

In daily clinical practice, an athlete is generally regarded as being fit to RTS if there is an absence of pain on palpation, absence of pain during strength and flexibility testing and asymptomatic completion of sports-specific testing. Despite this approach, re-injury rates remain high during the first two months after RTS57.

Clinical examination during the first week after RTS has been shown to be of significant value for identifying athletes at risk for re-injury. Significant independent predictors are the presence of localised discomfort on posterior thigh palpation, more degrees of active knee extension deficit, and isometric knee flexion force deficit at 15°58. With easy-to-assess clinical evaluation—performed by clinicians or physiotherapists—those athletes with an increased re-injury risk can be identified. These findings emphasise that it is of major importance to monitor the athlete in the first week after RTS58.

 

CONCLUSION

Simple clinical tests allow the practitioner to perform a reliable assessment to confirm the presence of hamstring injury. A lack of flexibility, strength, and pain on palpation are the main objective features, but more importantly, listen to the athlete. Very often elite athletes know their bodies well or have experienced similar injuries before. A detailed account of the injury mechanism and situation may provide valuable information in the assessment process. Understanding the goals and expectations of the athlete will ensure that both athlete, support team and medical team are all aligned to provide the best possible outcome for the individual.

 

 

 

Johannes L Tol M.D., Ph.D.

Sports Medicine Physician

Aspetar, Orthopedic and Sports Medicine

Hospital,

Doha, Qatar

 

Amsterdam University Medical Centers, Academic Medical Center, Amsterdam Amsterdam Movement Sciences, Academic Center for Evidence Based Medicine, Amsterdam IOC Center, ACHSS

Amsterdam, The Netherlands

 

Arnlaug Wangensteen Ph.D.

Physiotherapist

Oslo Sports Trauma Research Center, Department of Sports Medicine, Norwegian School of Sport Sciences

Oslo, Norway

 

Contact: Johannes.Tol@aspetar.com

 

 

References

  1. Whiting P, Harbord R, de Salis I, et al. Evidence-based diagnosis. J Health Serv Res Policy 2008;13 Suppl 3:57–63. doi:10.1258/jhsrp.2008.008025
  2. Järvinen TAH, Järvinen TLN, Kääriäinen M, et al. Muscle injuries: biology and treatment. Am J Sports Med 2005;33:745–64. doi:10.1177/0363546505274714
  3. Järvinen TA, Järvinen M, Kalimo H. Regeneration of injured skeletal muscle after the injury. Muscles Ligaments Tendons J 2013;3:337–45.
  4. Järvinen TAH, Järvinen TLN, Kääriäinen M, et al. Muscle injuries: optimising recovery. Best Pract Res Clin Rheumatol 2007;21:317–31. doi:10.1016/j.berh.2006.12.004
  5. Askling C. Type of acute hamstring strain affects flexibility, strength, and time to return to pre-injury level. Br J Sports Med 2006;40:40–4. doi:10.1136/bjsm.2005.018879
  6. Heiderscheit BC, Sherry MA, Silder A, et al. Hamstring strain injuries: recommendations for diagnosis, rehabilitation, and injury prevention. J Orthop Sports Phys Ther 2010;40:67–81.
  7. Kerkhoffs GMMJ, Es N, Wieldraaijer T, et al. Diagnosis and prognosis of acute hamstring injuries in athletes. Knee Surg Sports Traumatol Arthrosc 2012;21:500–9. doi:10.1007/s00167-012-2055-x
  8. Koulouris G, Connell D. Imaging of hamstring injuries: therapeutic implications. Eur Radiol 2006;16:1478–87. doi:10.1007/s00330-005-0075-3
  9. Koulouris G, Connell D. Hamstring muscle complex: an imaging review. Radiogr Rev Publ Radiol Soc N Am Inc 2005;25:571–86. doi:10.1148/rg.253045711
  10. Askling CM, Koulouris G, Saartok T, et al. Total proximal hamstring ruptures: clinical and MRI aspects including guidelines for postoperative rehabilitation. Knee Surg Sports Traumatol Arthrosc 2012;21:515–33. doi:10.1007/s00167-012-2311-0
  11. Schneider-Kolsky ME. A Comparison Between Clinical Assessment and Magnetic Resonance Imaging of Acute Hamstring Injuries. Am J Sports Med 2006;34:1008–15. doi:10.1177/0363546505283835
  12. Verrall GM, Slavotinek JP, Barnes PG, et al. Assessment of physical examination and magnetic resonance imaging findings of hamstring injury as predictors for recurrent injury. J Orthop Sports Phys Ther 2006;36:215–24. doi:10.2519/jospt.2006.36.4.215
  13. Askling CM, Tengvar M, Saartok T, et al. Acute first-time hamstring strains during high-speed running: a longitudinal study including clinical and magnetic resonance imaging findings. Am J Sports Med 2007;35:197–206. doi:10.1177/0363546506294679
  14. Askling CM, Tengvar M, Saartok T, et al. Acute First-Time Hamstring Strains During Slow-Speed Stretching: Clinical, Magnetic Resonance Imaging, and Recovery Characteristics. Am J Sports Med 2007;35:1716–24. doi:10.1177/0363546507303563
  15. Warren P, Gabbe BJ, Schneider-Kolsky M, et al. Clinical predictors of time to return to competition and of recurrence following hamstring strain in elite Australian footballers. Br J Sports Med 2010;44:415–9. doi:10.1136/bjsm.2008.048181
  16. Järvinen MJ, Lehto MU. The effects of early mobilisation and immobilisation on the healing process following muscle injuries. Sports Med Auckl NZ 1993;15:78–89.
  17. Askling CM, Malliaropoulos N, Karlsson J. High-speed running type or stretching-type of hamstring injuries makes a difference to treatment and prognosis. Br J Sports Med 2011;46:86–7. doi:10.1136/bjsports-2011-090534
  18. Schut L, Wangensteen A, Maaskant J, et al. Can Clinical Evaluation Predict Return to Sport after Acute Hamstring Injuries? A Systematic Review. Sports Med Auckl NZ 2017;47:1123–44. doi:10.1007/s40279-016-0639-1
  19. Brooks JHM. Incidence, Risk, and Prevention of Hamstring Muscle Injuries in Professional Rugby Union. Am J Sports Med 2006;34:1297–306. doi:10.1177/0363546505286022
  20. Woods C. The Football Association Medical Research Programme: an audit of injuries in professional football--analysis of hamstring injuries. Br J Sports Med 2004;38:36–41. doi:10.1136/bjsm.2002.002352
  21. Askling CM, Tengvar M, Thorstensson A. Acute hamstring injuries in Swedish elite football: a prospective randomised controlled clinical trial comparing two rehabilitation protocols. Br J Sports Med 2013;47:953–9. doi:10.1136/bjsports-2013-092165
  22. Opar MDA, Williams MD, Shield AJ. Hamstring Strain Injuries. Sports Med 2012;42:209–226.
  23. Brooks JHM, Fuller CW, Kemp SPT, et al. Epidemiology of injuries in English professional rugby union: part 2 training Injuries. Br J Sports Med 2005;39:767–75. doi:10.1136/bjsm.2005.018408
  24. Askling CM, Tengvar M, Tarassova O, et al. Acute hamstring injuries in Swedish elite sprinters and jumpers: a prospective randomised controlled clinical trial comparing two rehabilitation protocols. Br J Sports Med 2014;48:532–9. doi:10.1136/bjsports-2013-093214
  25. Askling C, Lund H, Saartok T, et al. Self-reported hamstring injuries in student-dancers. Scand J Med Sci Sports 2002;12:230–5.
  26. van der Made AD, Peters RW, Verheul C, et al. Abduction in Proximal Hamstring Tendon Avulsion Injury Mechanism-A Report on 3 Athletes. Clin J Sport Med Off J Can Acad Sport Med Published Online First: 1 December 2017. doi:10.1097/JSM.0000000000000543
  27. Koulouris G, Connell D. Evaluation of the hamstring muscle complex following acute injury. Skeletal Radiol 2003;32:582–9. doi:10.1007/s00256-003-0674-5
  28. Slavotinek JP, Verrall GM, Fon GT. Hamstring injury in athletes: using MR imaging measurements to compare extent of muscle injury with amount of time lost from competition. AJR Am J Roentgenol 2002;179:1621–8. doi:10.2214/ajr.179.6.1791621
  29. Ekstrand J, Healy JC, Waldén M, et al. Hamstring muscle injuries in professional football: the correlation of MRI findings with return to play. Br J Sports Med 2012;46:112–7. doi:10.1136/bjsports-2011-090155
  30. Chumanov ES, Heiderscheit BC, Thelen DG. Hamstring musculotendon dynamics during stance and swing phases of high-speed running. Med Sci Sports Exerc 2011;43:525–32. doi:10.1249/MSS.0b013e3181f23fe8
  31. Higashihara A, Ono T, Kubota J, et al. Functional differences in the activity of the hamstring muscles with increasing running speed. J Sports Sci 2010;28:1085–92. doi:10.1080/02640414.2010.494308
  32. Kyröläinen H, Avela J, Komi PV. Changes in muscle activity with increasing running speed. J Sports Sci 2005;23:1101–9. doi:10.1080/02640410400021575
  33. Simonsen EB, Thomsen L, Klausen K. Activity of mono- and biarticular leg muscles during sprint running. Eur J Appl Physiol 1985;54:524–32.
  34. Yu B, Queen RM, Abbey AN, et al. Hamstring muscle kinematics and activation during overground sprinting. J Biomech 2008;41:3121–6. doi:10.1016/j.jbiomech.2008.09.005
  35. Proske U, Morgan DL, Brockett CL, et al. Identifying athletes at risk of hamstring strains and how to protect them. Clin Exp Pharmacol Physiol 2004;31:546–50. doi:10.1111/j.1440-1681.2004.04028.x
  36. Brockett CL, Morgan DL, Proske U. Predicting hamstring strain injury in elite athletes. Med Sci Sports Exerc 2004;36:379–87.
  37. Thelen DG, Chumanov ES, Best TM, et al. Simulation of biceps femoris musculotendon mechanics during the swing phase of sprinting. Med Sci Sports Exerc 2005;37:1931–8.
  38. Schache AG, Wrigley TV, Baker R, et al. Biomechanical response to hamstring muscle strain injury. Gait Posture 2009;29:332–8. doi:10.1016/j.gaitpost.2008.10.054
  39. Heiderscheit BC, Hoerth DM, Chumanov ES, et al. Identifying the time of occurrence of a hamstring strain injury during treadmill running: a case study. Clin Biomech Bristol Avon 2005;20:1072–8. doi:10.1016/j.clinbiomech.2005.07.005
  40. Thelen DG, Chumanov ES, Hoerth DM, et al. Hamstring muscle kinematics during treadmill sprinting. Med Sci Sports Exerc 2005;37:108–14.
  41. Schache AG, Kim H-J, Morgan DL, et al. Hamstring muscle forces prior to and immediately following an acute sprinting-related muscle strain injury. Gait Posture 2010;32:136–40. doi:10.1016/j.gaitpost.2010.03.006
  42. Orchard JW. Hamstrings are most susceptible to injury during the early stance phase of sprinting. Br J Sports Med 2012;46:88–9. doi:10.1136/bjsports-2011-090127
  43. Orava S, Kujala UM. Rupture of the ischial origin of the hamstring muscles. Am J Sports Med 1995;23:702–5.
  44. van der Made AD, Tol JL, Reurink G, et al. Potential hamstring injury blind spot: we need to raise awareness of proximal hamstring tendon avulsion injuries. Br J Sports Med 2018;:bjsports-2018-100063. doi:10.1136/bjsports-2018-100063
  45. Verrall GM, Slavotinek JP, Barnes PG, et al. Diagnostic and prognostic value of clinical findings in 83 athletes with posterior thigh injury: comparison of clinical findings with magnetic resonance imaging documentation of hamstring muscle strain. Am J Sports Med 2003;31:969–73.
  46. Malliaropoulos N, Papacostas E, Kiritsi O, et al. Posterior thigh muscle injuries in elite track and field athletes. Am J Sports Med 2010;38:1813–9. doi:10.1177/0363546510366423
  47. Malliaropoulos N, Papalexandris S, Papalada A, et al. The Role of Stretching in Rehabilitation of Hamstring Injuries: 80 Athletes Follow-Up. Med Sci Sports Exerc 2004;:756–9. doi:10.1249/01.MSS.0000126393.20025.5E
  48. Gajdosik RL, Rieck MA, Sullivan DK, et al. Comparison of four clinical tests for assessing hamstring muscle length. J Orthop Sports Phys Ther 1993;18:614–8. doi:10.2519/jospt.1993.18.5.614
  49. Davis DS, Quinn RO, Whiteman CT, et al. Concurrent validity of four clinical tests used to measure hamstring flexibility. J Strength Cond Res 2008;22:583–8. doi:10.1519/JSC.0b013e31816359f2
  50. Reurink G, Goudswaard GJ, Oomen HG, et al. Reliability of the Active and Passive Knee Extension Test in Acute Hamstring Injuries. Am J Sports Med Published Online First: 4 June 2013. doi:10.1177/0363546513490650
  51. Maniar N, Shield AJ, Williams MD, et al. Hamstring strength and flexibility after hamstring strain injury: a systematic review and meta-analysis. Br J Sports Med 2016;50:909–20. doi:10.1136/bjsports-2015-095311
  52. Kornberg C, Lew P. The effect of stretching neural structures on grade one hamstring injuries. J Orthop Sports Phys Ther 1989;10:481–7.
  53. Speer KP, Lohnes J, Garrett WE. Radiographic imaging of muscle strain injury. Am J Sports Med 1993;21:89–95; discussion 96.
  54. Eberbach H, Hohloch L, Feucht MJ, et al. Operative versus conservative treatment of apophyseal avulsion fractures of the pelvis in the adolescents: a systematical review with meta-analysis of clinical outcome and return to sports. BMC Musculoskelet Disord 2017;18:162. doi:10.1186/s12891-017-1527-z
  55. McKinney BI, Nelson C, Carrion W. Apophyseal avulsion fractures of the hip and pelvis. Orthopedics 2009;32:42.
  56. Gidwani S, Bircher MD. Avulsion injuries of the hamstring origin - a series of 12 patients and management algorithm. Ann R Coll Surg Engl 2007;89:394–9. doi:10.1308/003588407X183427
  57. Wangensteen A, Tol JL, Witvrouw E, Van Linschoten R, Almusa E, Hamilton B, Bahr R. Hamstring reinjuries occur at the same location and early after return to sport: a descriptive study of MRI-confirmed reinjuries. The American journal of sports medicine. 2016 Aug;44(8):2112-21.
  58. De Vos R-J, Reurink G, Goudswaard G-J, et al. Clinical findings just after return to play predict hamstring re-injury, but baseline MRI findings do not. Br J Sports Med 2014;48:1377–84. doi:10.1136/bjsports-2014-093737

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