Recommendations for Diagnosis, Rehabilitation and Injury Prevention. Bryan C. Heiderscheit, P. T., Ph. D., Associate Professor,1. Marc A. Sherry, P.
T., L. A. T., C. S. C. S, Director,2.
Amy Silder, Ph. D., Research Associate,3. Elizabeth S. Chumanov, Ph. D., Research Associate,4 and Darryl G. Thelen, Ph. D., Associate Professor.
Department of Orthopedics and Rehabilitation, University of Wisconsin- Madison, Madison, WI2 Sports Rehabilitation, University of Wisconsin Health Sports Medicine Center, Madison, WI3 Department of Biomedical Engineering, University of Wisconsin- Madison, Madison, WI4 Department of Orthopedics and Rehabilitation, University of Wisconsin- Madison, Madison, WI5 Department of Mechanical Engineering, University of Wisconsin- Madison, Madison, WICorresponding Author: Bryan Heiderscheit, PT, Ph. D, University of Wisconsin School of Medicine and Public Health, Department of Orthopedics and Rehabilitation, 1. University Ave MSC 4. Madison, WI 5. 37.
Email: ude. csiw. See other articles in PMC that cite the published article. Synopsis. Hamstring strain injuries remain a challenge for both athletes and clinicians given the high incidence rate, slow healing, and persistent symptoms. Moreover, nearly one- third of these injuries recur within the first year following a return to sport, with subsequent injuries often being more severe than the original.
ROSA mT/mG is a cell membrane-targeted, two-color fluorescent Cre reporter allele; expressing cell membrane-localized red fluorescence in widespread cells. Hamstring strain injuries remain a challenge for both athletes and clinicians given the high incidence rate, slow healing, and persistent symptoms.
This high reinjury rate suggests that commonly utilized rehabilitation programs may be inadequate at resolving possible muscular weakness, reduced tissue extensibility, and/or altered movement patterns associated with the injury. Further, the traditional criteria used to determine the readiness of the athlete to return to sport may be insensitive to these persistent deficits, resulting in a premature return. There is mounting evidence that the risk of reinjury can be minimized by utilizing rehabilitation strategies that incorporate neuromuscular control exercises and eccentric strength training, combined with objective measures to assess musculotendon recovery and readiness to return to sport. In this paper, we first describe the diagnostic examination of an acute hamstring strain injury, including discussion of the value of determining injury location in estimating the duration of the convalescent period. Based on the current available evidence, we then propose a clinical guide for the rehabilitation of acute hamstring injuries including specific criteria for treatment progression and return to sport. Finally, we describe directions for future research including injury- specific rehabilitation programs, objective measures to assess reinjury risk, and strategies to prevent injury occurrence.
Level of evidence: Diagnosis/therapy, level 5. Keywords: functional rehabilitation, muscle strain injury, radiology/medical imaging, running, strength training. Hamstring strain injuries comprise a substantial percentage of acute musculoskeletal injuries incurred during sporting activities at the high school, collegiate, and professional levels. Participants in track, football, and rugby are especially prone to this injury given the sprinting demands of these sports,1. Over a 1. 0- year span among the players of 1 National Football League team (1.
The sarcoplasm is the cytoplasm of a muscle fiber. Most of the sarcoplasm is filled with myofibrils, which are long protein cords composed of myofilaments.
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The average number of days lost to this injury ranges from 8 to 2. Of potentially greater concern is that one- third of the hamstring injuries will recur with the greatest risk during the initial 2 weeks following return to sport. This high early reinjury rate is suggestive of an inadequate rehabilitation program,2. The occurrence of hamstring strain injuries during high- speed running is generally believed to occur during terminal swing phase of the gait cycle,3.
During the second half of swing, the hamstrings are active, lengthening and absorbing energy from the decelerating limb in preparation for foot contact. The greatest musculotendon stretch is incurred by the biceps femoris,9. FIGURE 1). 7 Running- related hamstring strain injuries typically occur along an intramuscular tendon or aponeurosis, and the adjacent muscle fibers. During its recovery from injury, the hamstrings must be properly rehabilitated to safely handle high eccentric loading upon return to running. Hamstring injuries that occur during activities such as dancing or kicking can occur during either slow or fast movements that involve simultaneous hip flexion and knee extension.
Such movements place the hamstrings in a position of extreme stretch, with injuries most commonly presenting in the semimembranosus and its proximal free tendon (as opposed to the intramuscular tendon). These injuries tend to require a prolonged recovery period before an individual is able to return to the pre- injury level of performance.
Despite differences in injury mechanisms and recovery time, current examination and rehabilitation approaches generally do not consider injury location (i. Achieving this objective requires consideration of the musculoskeletal deficits directly resulting from the injury (eg, swelling, pain, weakness, loss of range of motion), as well as risk factors that may have been present prior to the injury.
While the age of the individual and a prior history of a hamstring strain have been consistently identified as injury risk factors,1. Modifiable risk factors that have been suggested include hamstring weakness, fatigue, and lack of flexibility.
In addition, limited quadriceps flexibility. As a result, current rehabilitation programs typically include a combination of interventions targeted at each of these modifiable factors. The purposes of this clinical commentary are: 1) to describe the diagnostic examination of the acute hamstring strain injury with emphasis on tests and measures that have prognostic value; 2) to present a comprehensive rehabilitation guide based on existing evidence aimed at minimizing both the convalescent period and risk of injury recurrence; and 3) to suggest future directions for research into injury mechanisms and recovery, with the goal of developing better prevention and more individualized rehabilitation programs. Examination. History. The majority of individuals with hamstring strain injuries will present in the acute setting with a sudden onset of posterior thigh pain resulting from a specific activity, most commonly high- speed running.
Athletes may describe the occurrence of an audible pop with the onset of pain, more common to injuries involving the proximal tendon,9 and are generally limited by the pain from continuing in the activity. Individuals may also report having pain at the ischial tuberosity when sitting, most commonly when the proximal tendon(s) is involved. Because hamstring strain injuries have a high rate of recurrence, patients may report a previous hamstring injury, which is often adjacent to or near the current site of injury. The mechanism of injury, and subsequent tissues injured, have been shown to have important prognostic value in estimating the rehabilitation time needed to return to pre- injury level of performance (TABLES 1 and .
This finding is consistent with prior observation that injuries involving the free tendon require a longer rehabilitation period than those within the muscle tissue. Severe injuries, such as complete or partial ruptures of the hamstring muscles, typically result from extreme and forceful hip flexion with the knee fully extended (eg, water skiing),2. Although a differential examination is always recommended, the absence of a specific injury mechanism should lead the examiner to consider other potential sources of posterior thigh pain (TABLE 3). Physical Examination. In the event of high suspicion of a hamstring injury based on the injury mechanism and sudden onset of symptoms, the purpose of the physical examination is more to determine the location and severity of the injury than its presence.
Hamstring strain injuries are commonly classified according to the amount of pain, weakness, and loss of motion, resulting in grades of I (mild), II (moderate), or III (severe). These injury grades are considered to reflect the underlying extent of muscle fiber or tendon damage (eg, grade I having minimal damage with grade III being complete tear or rupture), and can be used to estimate the convalescent period and to design the appropriate rehabilitation program. For injuries involving the intramuscular tendon and adjacent muscle fibers, a battery of tests that measure strength, range of motion, and pain can provide a reasonable estimate of rehabilitation duration. In fact, the actual rehabilitation duration was shown to be as predictable from this clinical test combination as from measures of injury severity obtained from a magnetic resonance (MR) image. However, for injuries to the proximal free tendon, the amount of impairment identified from these tests are not predictive of the recovery time needed to return to pre- injury level. Regardless, we recommend the following specific measures, as described below, be used during the examination of all acute hamstring injuries, at the very least to serve as a baseline from which progress can be assessed. These tests should be considered as part of a comprehensive examination to identify deficits in adjacent structures that may have contributed to the hamstring injury (eg, strength of lumbopelvic muscles; quadriceps tightness).
Strength Strength assessment of the hamstring muscles is recommended through manual resistance applied about the knee and hip. Due to the biarticular nature of the hamstring muscles and the accompanying changes in musculotendon length that occur with hip and knee flexion, multiple test positions are utilized to assess isometric strength and pain provocation.
For example, with the patient in a prone position and the hip stabilized at 0. Attempts to bias the medial or lateral hamstrings by internal or external rotation of the lower leg, respectively, during strength testing may assist in the determination of the involved muscles.
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