HAMSTRING CONTRACTION 1 The Role of Hamstring Contraction ...
Hamstring Strain Injuries - Aspetar Experience Nicol van Dyk & Philipp Jacobsen
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Transcript of Hamstring Strain Injuries - Aspetar Experience Nicol van Dyk & Philipp Jacobsen
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