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Hamstring Strain Injuries - Aspetar Experience Nicol van Dyk & Philipp Jacobsen
1. Assessment & Treatment
of
HAMSTRING STRAIN
INJURIES
Presented by
Nicol van Dyk
Philipp Jacobsen
Rehabilitation Department
Aspetar Sports Medicine and Orthopaedic Hospital
2. Aim
• Overview
• Our main findings
• Return to Sport (RTS)
• Predictors for RTS
• Daily assessment
• Criteria based progression protocol
@NicolvanDyk
3. Background
• Concurrent study with large RCT study
• Main contributors
– Rod Whiteley
– Patrice Muxart
– Philipp Jacobsen
– Arnlaug Wagensteen
5. Setting the scene
• 24yr old
professional
• 1st HSI 1 day ago
• Left HS Grade II BF
(MRI confirmed)
6. Background
Basic clinical question:
What do measure?
&
Why?
Return to Sport (RTS) after HSI
• Similar Grading
• Similar sporting requirements
1 - >50weeks reported
8. • What we did
– Assessment protocol
– Treatment protocol
•HSI Grade I
•HSI Grade II
• What we found
– Return to Sport (RTS)
– Predictors of RTS
PLAN
9. • Initial Assessment
• Daily Assessment
• Treatment
• Discharge Criteria
(All based on clinical agreement following a
Pseudo Delphi Method)
What we did
12. Initial Assessment
• History
• Mechanism
• Pain
• Past History
• Gait
• Palpation
• Flexibility
• Active Movement
Sprinting
Twist/Change
direction
Kicking
Other
Stance/swing leg?
13. Initial Assessment
• History
• Mechanism
• Pain
• Past History
• Gait
• Palpation
• Flexibility
• Active Movement
Maximum pain at the
time of injury VAS
Average pain today
15. Initial Assessment
• History
• Mechanism
• Pain
• Past History
• Gait
• Palpation
• Flexibility
• Active Movement
Walking
Normal / Antalgic / Needs aid
Jogging
Normal / Antalgic / Needs aid
16. Initial Assessment
• History
• Mechanism
• Pain
• Past History
• Gait
• Palpation
• Flexibility
• Active Movement
Length of pain (cm)
17. Initial Assessment
• History
• Mechanism
• Pain
• Past History
• Gait
• Palpation
• Flexibility
• Active Movement
• Aspetar HS Flexibility
Test
18. Initial Assessment
• History
• Mechanism
• Pain
• Past History
• Gait
• Palpation
• Flexibility
• Active Movement
Standardized bridge
19. • Strength Measurements
– Hand held Dynomometer
– Standardized Protocol
– 3 repetitions
– Clinically meaningful test positions
Initial Assessment
22. Passive
movement
Massage – no
pain
Massage -
discomfort
Active range of
motion
Eccentric outer
range
Slow run
Concentric
through range
Fast run
Direction change
Isometric – inner
range
Eccentric inner
range
Outer range
ballistic
Stretching Trunk control Cardio (bike)
Isometric outer
range
1Painless single leg squat
Painless bike 2XBW, 5 mins
Full knee Ext supine
2Run > 70%
ROM SLR & HS Θ > 75%
3100% running
Painless direction change
23. Principles (after experience)
• Reassess and
compare:
– Average pain
– Palpation pain
length
– Strength
(mid/outer)
– (Flexibility)
• Progress
• Regress
• Stay at the same
level
27. Treatment Outcomes
n: 90
Days to 1st
treatment
Days to discharge Days of treatment
Mean 3.26 23.19 19.93
Median 3 20 17
Min 0 11 7
Max 8 55 51
SD 1.48 8.40 8.24
31. Week 1 Exam
• - 97.8 days
• Plus
– 0.4 PTHC60U
– 4.5 MaxP
– 3 TimeWalk
• Less
– 11.25 (OutInjP)
– 16.5 (Mid%)
– 8.1 (SportVolleyball)
97% Variance
explained
5 days
32.
33. What are the important measurements?
Outer
Range
Strength
Max P @ injury
Start treatment early
Length of pain (palpation)
Playing football
Hamstring flexibility
Forward bending
Bridge
Mid Range
Strength
40. What are the important measurements?
Outer
Range
Strength
Max P @ injury
Start treatment early
Length of pain (palpation)
Playing football
Hamstring length
Forward bending
Bridge
Mid Range
Strength
44. Case Presentation
• 24yr old professional
• Left HS Grade II BF
(MRI confirmed)
• 1st HSI 11 day ago
• Stage 2
• Started Lengthening
Ex’s
• 50% running
45. Daily assessment
• Average VAS 0
• P free walking
• P free squat and Bridge
• Palpation P 3 cm
• P free ROM
Strength (kg) Injured Uninjured
Outer Range
19.3 30.2
Mid Range
17.3 36.3
47. Daily assessment
Next day
• Trunk flexion : P
• Palpable P 20 cm (DOMS)
• ROM SLR + MHFAKE 30% & P
• Bridge P
Strength (kg) Injured Uninjured
Outer Range
15.8(19.3) 30.2
Mid Range
11.6(17.3) 36.3
48. Take Home message
• Difficult to predict RTS
• Structured Daily Monitoring
• Progressive criteria based programme
• Measure what matters
50. • Askling C, Saartok T, Thorstensson A. Type of acute hamstring strain affects flexibility, strength, and time
• to return to pre-injury level. Br J Sports Med 2006; 40(1):40-44.
• Askling CM, Nilsson J, Thorstensson A. A new hamstring test to complement the common clinical
• examination before return to sport after injury. Knee Surg Sports Traumatol Arthrosc 2010; 18(12):1798-
• 1803.
• Opar, DA, Piatkowski, T, Williams, MD, Shield, AJ. A Novel Device Using the Nordic Hamstring Exercise to
• Asess Eccentric
• 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
• Pincivero, Lephart, & Karunakara, 1997
• Schneider-Kolsky ME, Hoving JL, Warren P, Connell DA. A comparison between clinical assessment and
• magnetic resonance imaging of acute hamstring injuries. Am J Sports Med 2006; 34(6):1008-1015.
• Thorborg K, Bandholm T, Holmich P. Hip- and knee-strength assessments using a hand-held
• dynamometer with external belt-fixation are inter-tester reliable. Knee Surg Sports Traumatol Arthrosc
• 2013; 21(3):550-555.
• Tol et al 2014
• Whiteley et al (2012)_ Correlation of isokinetic and novel hand-held dynamometry measures of knee
• flexion and extension strength testing JSAMS
References
Firstly thank you to Dr Landreau and the organizing committee for the opportunity to hare with you our Aspetar Experience in Hamstring Musde Injuries
Lets give you our framework for today. We will briefly overview our hamstring project and the ongoing interest in HSi in our dept. Then we want to share with you the main findings of our research, as well as what we have found to be clinically useful. For the most part, we will be focusing on the practical elements – and Philipp will be presenting our daily assessment and our progression protocol, as well as sharing the clinical tips when performing this assessment that we have found useful
You should all have received a handout, which has all the information contained in our presentation. But for those who are interested, I will put up a link on twitter for the slides in our presentation today, and there is my twitter handle for you to follow
So of course we have many contributors, Rod Whiteley you may have heard already and Philipp who is presenting with me. We Would like to acknowledge our late collegue, Patrice Muxart, who passed away last year. He played a big role and made massive contribution to this project and the development of our hamstring protocol.I would also like to mention the NSMP Dr’s and PT’s without whom we would not be able to do any of this work. We owe a big thanks to them for always supporting these efforts to include our clinical practice.
Then I would just like to mention Arnlaug Wagensteen…
So what could be better than getting a former Norwegian female handball player to add to our expertise.
And this is what we expected! And this is what we got! But we are indeed very grateful that Arnlaug has traded her Norwegian mountains for a Aspetar uniform, she has made an incredible contribution to where we are today.
Now let’s imagine we have this scenario. Abdallah is a 24yr old…. How long do you think it would take for him to return to sport? 10d? 20d? 40d?
Hold on to that number and we will show what we found
In the literature, that is actually there is also a relatively broad answer. Now, do actually know why we measure certain things? Do we know if what we measure are important? This is exactly what we wanted to answer
Well, this is the question we are always asked, and usually it’s not only the player, but also the coach and the team management. How do we answer this question? So indeed, this was the question we asked ourself: (Next slide
Sudden onset
Pain localised? (not referred)
Game/training
Forced to stop (5 mins)
Keep running?
Walk pain free immediately?
How long until pain free walk?
Previous hamstring injury?
This leg, other leg
LBP
Knee / Groin / Calf
Other Injury
Surgery
Distance to ischial tuberosity was measured, as well as the length of pain which we also have in our daily assessment
SLR
Hamstring Θ
“MHFAKE”
All our strength test was performed with a HHD, and make it as standardized as possible.
Philipp will go into more detail regarding our daily assessment, but here is a quick summary of what our daily assessment contains
Pain – average P today?Gait – walk/jog/aided
Flexibility – Bending, SLR, Aspetar Test
Passive (soft tissue)
Passive movement
Active movement
Stretching
Strengthening
Eccentric & Concentric
Running Progression
Functional
Discharge Criteria
Recommendations
1 X 50% training session
2 X full training sessions
Reduced 1st match (50% or 30min)
Full Match RTS
Discharge Criteria
Completed 3 X Sport Specific
Performed Isokinetic Test
All initial tests completed
No major imbalances
Recommendations
1 X 50% training session
2 X full training sessions
Reduced 1st match (50% or 30min)
Full Match RTS
So remember this guy? How long did you think he would take to get back? Now if we had to say to him on day 1, we would say this based on the 90 subjects we have included.
This is all the possible measurements we threw into the analysis.
Best possible combinations that would yield a result. Adjusted R2 (variance explained) how these variables contribute
What does this mean for us clinically? Well, with only 8.6% of variance explained,
So this seems to be the indicators that we need to pay attention too. Now from that initial slide where we had all of them, these are the ones to pay attention to. Now, on the basis of 90 patients, I won’t tell you to discount 100 years of clinical experience, and at this stage we are still considering that. Although I would suggest that these are the ones we need to pay more attention to.
Main focus on healing process , Rice only if patient is seen first thing after injury
Increase the load of exercises from stage one
Introduce running progression
Progression criteria: run more than 70% self rated max speed
Progress Strength exercise (weight and speed)
Introduce eccentric lengthening exercises
Running progression up to 100% self rated running speed.
Introduce change of directions
T test
So this seems to be the indicators that we need to pay attention too. Now from that initial slide where we had all of them, these are the ones to pay attention to. Now, on the basis of 90 patients, I won’t tell you to discount 100 years of clinical experience, and at this stage we are still considering that. Although I would suggest that these are the ones we need to pay more attention to.
Palpation – length of pain
Pain – VAS
Gait – walking jogging
Flexibility – Aspetar Test
Strength – HHD
Functional Test – squat, trunk flexion and bridge
Now let’s imagine we have this scenario. Abdallah is a 24yr old…. How long do you think it would take for him to return to sport? 10d? 20d? 40d?
Structured Daily Monitoring makes a difference, you need to focus on the measures that give you information
A criteria based programme seems more effective
It remains extremely difficult to predict return to sport