Assessment & Treatmentof

HAMSTRING STRAIN INJURIES

Presented by

Nicol van DykPhilipp JacobsenRehabilitation DepartmentAspetar Sports Medicine and Orthopaedic Hospital

Aim

• Overview

• Our main findings• Return to Sport (RTS)

• Predictors for RTS

• Daily assessment

• Criteria based progression protocol

@NicolvanDyk

Background

• Concurrent study with large RCT study

• Main contributors

– Rod Whiteley

– Patrice Muxart

– Philipp Jacobsen

– Arnlaug Wagensteen

We needed some Handball expertise

Setting the scene

• 24yr old professional

• 1st HSI 1 day ago

• Left HS Grade II BF(MRI confirmed)

Background

Basic clinical question:

What do measure?

&

Why?

Return to Sport (RTS) after HSI• Similar Grading • Similar sporting requirements

1 - >50 weeks reported

“When can I play again?”

• What we did

– Assessment protocol

– Treatment protocol

•HSI Grade I

•HSI Grade II

• What we found

– Return to Sport (RTS)

– Predictors of RTS

PLAN

• Initial Assessment

• Daily Assessment

• Treatment

• Discharge Criteria

(All based on clinical agreement following a Pseudo Delphi Method)

What we did

Initial Assessment

Initial Assessment

• History• Mechanism

• Pain

• Past History

• Gait

• Palpation

• Flexibility

• Active Movement

Initial Assessment

• History

• Mechanism• Pain

• Past History

• Gait

• Palpation

• Flexibility

• Active Movement

Sprinting

Twist/Change direction

Kicking

Other

Stance/swing leg?

Initial Assessment

• History

• Mechanism

• Pain• Past History

• Gait

• Palpation

• Flexibility

• Active Movement

Maximum pain at the time of injury VAS

Average pain today

Initial Assessment

• History

• Mechanism

• Pain

• Past History• Gait

• Palpation

• Flexibility

• Active Movement

Initial Assessment

• History

• Mechanism

• Pain

• Past History

• Gait• Palpation

• Flexibility

• Active Movement

WalkingNormal / Antalgic / Needs aid

JoggingNormal / Antalgic / Needs aid

Initial Assessment

• History

• Mechanism

• Pain

• Past History

• Gait

• Palpation• Flexibility

• Active Movement

Length of pain (cm)

Initial Assessment

• History

• Mechanism

• Pain

• Past History

• Gait

• Palpation

• Flexibility• Active Movement

• Aspetar HS Flexibility Test

Initial Assessment

• History

• Mechanism

• Pain

• Past History

• Gait

• Palpation

• Flexibility

• Active Movement

Standardized bridge

• Strength Measurements

– Hand held Dynomometer

– Standardized Protocol

– 3 repetitions

– Clinically meaningful test positions

Initial Assessment

Daily Assessment

PainFunctional Tests

Strength

FlexibilityGait

Treatment Protocol

Passive movement

Massage – no pain

Massage -discomfort

Active range of motion

Eccentric outer range

Slow runConcentric

through rangeFast run

Direction changeIsometric – inner

rangeEccentric inner

rangeOuter range

ballistic

Stretching Trunk control Cardio (bike)Isometric outer

range

1Painless single leg squat

Painless bike 2XBW, 5 minsFull knee Ext supine

2 Run > 70%

ROM SLR & HS Θ > 75%

3 100% running

Painless direction change

Principles (after experience)

• Reassess and compare:

– Average pain

– Palpation pain length

– Strength (mid/outer)

– (Flexibility)

• Progress

• Regress

• Stay at the same level

Discharge Criteria & Recommendations

Discharge Criteria & Recommendations

What we foundTreatment Outcomes

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

Pain today

Injury Mechanism

Size of injury

SLR Flexibility

Strength

Squatting

Walking Running

Bent leg bridge

Neural involvement

Injury Location

HS ϴFlexibility

Past history

Palpable defect

Forward flexion

Side injured

Hip Extension Painless?

SIJ Involved?

Level of play

Hours/ week

Straight leg

bridge

Pain at injury?

Wt.B or NWB leg?

Something else?

So how did we analyze this?

Regression Analysis

“Not everything that counts can be counted, and not everything that can be counted counts.”

Einstein/Cameron

• Initial Exam

– 50.3% variance explained (± 23 days)

• MRI parameters

– 8.6% variance explained (± 40 days)

– When combined – 3% extra variance explained

• 1 Week Exam

– 97% variance explained (± 5 days)

Results

X

X

√

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)

– .33 (SLRUninj)

97% Variance explained5 days

What are the important measurements?

Outer

Range

StrengthMax P @ injury

Start treatment early

Length of pain (palpation)

Playing footballHamstring flexibility

Forward bending

BridgeMid Range Strength

Protocol & Daily Assessment

The Protocol

• 3 Stage protocol

• Set criteria to progress

• Daily reassessment

• On field Sport Specific Rehabilitation

Stage One

Progression criteria:

• Bike 2 X BW (Power) 5 min

• Pain free single leg squat

Stage Two

Progression criteria

• Run >70%

• SLR & HS Θ > 75%

RunningProgression

• Walk

• Jog

• Run

• Triple extension

• Late swing (“A drill”)

• Direction change

Stage three

Progression Criteria• 100% running • T-test completed• No strength deficit

What are the important measurements?

Outer

Range

StrengthMax P @ injury

Start treatment early

Length of pain (palpation)

Playing footballHamstring length

Forward bending

BridgeMid Range Strength

Daily Assessment

Pain

Gait

Flexibility

(ROM)

Strength

Functional

TestPalpation

Tools

Practical Demonstration

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

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

Exercise progression

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

Take Home message

• Difficult to predict RTS

• Structured Daily Monitoring

• Progressive criteria based programme

• Measure what matters

Thank you

• 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

Functional assessment

Midrange Strength

Outer Range Strength

Range of Motion

T Test