![UW Neuromuscular
Biomechanics
Lab
Predicting Time to Return to Sport
and Re-injury from MRI
MRI measures associated with increased recovery time:
Baseline: cradio-caudal length of injury on MRI (r=0.41)
Post-rehabilitation: none
Baseline MRI measures associated with re-injury
Cross sectional area of injury (% of total cross sectional
area)
Re-injury (n=4): 87% [95% CI: 68%, 100%]
No re-injury (n=25): 54% [95% CI: 43%, 65%]
Silder et al. (2013) J Orthop Sports Phys Ther](https://image.slidesharecdn.com/17muscletech14hamstringmrheiderscheit-141014075715-conversion-gate02/85/Bryan-Heiderscheit-MRI-findings-25-320.jpg)
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Bryan Heiderscheit - MRI findings
The document discusses MRI findings related to hamstring strain injuries and recovery, emphasizing the correlation between injury severity and recovery time. It highlights the increased risk of re-injury associated with specific factors such as previous strain injuries and persistent deficits in muscle function. The conclusions stress that a significant proportion of muscle remains injured at the time of return to sport, often accompanied by scar tissue formation and strength deficits.
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- 1. UW Neuromuscular Biomechanics Lab MRI FindingsRegarding Hamstring Strain Injury and Recovery Bryan Heiderscheit, PT, PhD Professor Department of Orthopedics and Rehabilitation Department of Biomedical Engineering Director, UW Runners’ Clinic Director, Badger Athletic Performance Research Co-director, UW Neuromuscular Biomechanics Lab
- 2. UW Neuromuscular Biomechanics Lab MRI Use MRI typically reserved when rupture is suspected Provide estimate of recovery time injury length and cross sectional area (CSA) proportional to time away from sport Heiderscheit et al (2010) J Orthop Sports Phys Ther Connell et al (2004) Am J Roentgenol Slavotinek et al (2002) Am J Roentgenol
- 3. UW Neuromuscular Biomechanics Lab Can MRIpredict Re-injury Risk? Gibbs et al (2004) J Sci Med Sport Koulouris et al (2007) Am J Sports Med Verrall et al (2006) J Orthop Sports Phys Ther Warren et al (2010) Br J Sports Med Ekstrand et al (2011) Br J Sports Med re-injury is most common with: injury to biceps femoris history of hamstring strain injury injuries that present as more severe, based on initial physical exam or MRI findings, do not have greater rate of injury recurrence characterizing the extent of musculotendon recovery at time of return to sport may provide prognostic value regarding re-injury risk
- 4. UW Neuromuscular Biomechanics Lab Increased Riskof Re-injury Recurrent Strain Injury Initial Strain Injury persistent deficits Weakness Altered musculotendon dynamics Scar tissue
- 5. UW Neuromuscular Biomechanics Lab Prior HamstringStrain Injury Recurrent Strain Injury Initial Strain Injury persistent deficits Weakness Altered musculotendon dynamics Scar tissue Project 1
- 6. UW Neuromuscular Biomechanics Lab Longitudinal Changes Recurrent StrainInjury Initial Strain Injury persistent deficits Weakness Altered musculotendon dynamics Scar tissue Project 2
- 7. UW Neuromuscular Biomechanics Lab Volume Estimatesfrom MRI Silder et al. (2008) Skel Radiol
- 8. UW Neuromuscular Biomechanics Lab Muscle VolumeChanges BFLH BFSH -12% **p<0.01 +22% **p=0.06 Injured Healthy **Compared to healthy controls Silder et al. (2008) Skel Radiol
- 9. UW Neuromuscular Biomechanics Lab Persistent ScarTissue Silder et al. (2008) Skel Radiol 92% increase in biceps tendon volume healthy controls, ~10% absolute bilateral difference 8 months post-injury
- 10. UW Neuromuscular Biomechanics Lab Fatty Infiltration Inconsistent finding of greater fatty infiltration on previously injured side (white arrow) compared to non-injured side (black arrow) Silder et al. (2008) Skel Radiol
- 11. UW Neuromuscular Biomechanics Lab Silder etal. (2010) Clin Biomech No significant bilateral differences in peak musculotendon stretch Symmetrical Running Mechanics
- 12. UW Neuromuscular Biomechanics Lab Muscle-Tendon Dynamics Muscle tissue strain largely dependent on tendon compliance Normal Tendon Tendon/Scar Lieber et al., Am J Physiol, 1991 Thelen et al., Med Sci Sports Exerc, 2005 Fukashiro et al., J Appl Biomech, 2006 Greater muscle fiber strain with increased tendon stiffness
- 13. UW Neuromuscular Biomechanics Lab MRI CompatibleLoading Device Elastic Loading Inertial Loading 28 cycles/min ~15-20% of maximum strength Silder et al (2010) J Biomechanics
- 14. UW Neuromuscular Biomechanics Lab 28cycles/min 1’39” per scan 1.4 x 1.4 x 6 mm Dynamic Hamstring Imaging Proximal Tendon and Aponeurosis Biceps Femoris Long Head
- 15. UW Neuromuscular Biomechanics Lab Proximal tendonand aponeurosis Four regions 0-1 cm 1-2 cm 2-3 cm 3-4 cm Regional Comparisons within Biceps Femoris Long Head Silder et al (2010) J Biomechanics
- 16. UW Neuromuscular Biomechanics Lab Tissue Displacements Elasticvs Inertial Loading 6 4 2 0 Displacement (mm)Elastic Loading Inertial Loading Proximal tissue moved least for both loading conditions Greater overall muscle displacement More uniform motion, but larger gradients near proximal MTJ Silder et al (2010) J Biomechanics
- 17. UW Neuromuscular Biomechanics Lab Tissue Displacements Healthyvs Previously Injured Healthy Injured Inertial Loading Silder et al (2010) J Biomechanics Least displacement in proximal region of injured, adjacent to MTJ
- 18. UW Neuromuscular Biomechanics Lab First PrincipalStrains Inertial Loading Healthy Injured 0.15 0.10 0.05 0.00 Strain Silder et al (2010) J Biomechanics
- 19. UW Neuromuscular Biomechanics Lab First PrincipalStrains Healthy vs Injured Largest strains adjacent to MTJ Strains greater for injured subjects Healthy Injured Inertial Loading Silder et al (2010) J Biomechanics
- 20. UW Neuromuscular Biomechanics Lab Longitudinal Changes Recurrent StrainInjury Initial Strain Injury persistent deficits Weakness Altered musculotendon dynamics Scar tissue Project 2
- 21. UW Neuromuscular Biomechanics Lab Morphological andStrength Changes during Recovery Acute hamstring strain injury Standardized Rehabilitation Return to Sport 6 month F/U from Return to Sport MRI MRI & strength MRI & strength 7 day window
- 22. UW Neuromuscular Biomechanics Lab Muscle Recoveryafter Rehabilitation 10 days post-injury 30 days post-injury Cleared to return to sport at 23 days post-injury Heiderscheit et al (2010) J Orthop Sports Phys Ther Sanfilippo et al (2013) Med Sci Sports Exerc persistent edema ~20% of muscle still shows evidence of injury on MRI at time of return to sport evidence of scar formation
- 23. UW Neuromuscular Biomechanics Lab Post-Injury Remodeling Persistent edema Evidence of scar tissue Silder et al. (2008) Skeletal Radiology Connell et al. (2004) AJR 7 days post-injury 2 mo. post-injury 7 mo. post-injury Edema resolved Fully formed scar tissue
- 24. UW Neuromuscular Biomechanics Lab 7 dayspost-injury 2 mo. post-injury 7 mo. post-injury Predicting Scar Tissue Moderate correlation (r=0.49) between volume of initial injury and subsequent size of scar Davidson et al. (2011) Proc, N Am Soc Clin Radiol
- 25. UW Neuromuscular Biomechanics Lab Predicting Timeto Return to Sport and Re-injury from MRI MRI measures associated with increased recovery time: Baseline: cradio-caudal length of injury on MRI (r=0.41) Post-rehabilitation: none Baseline MRI measures associated with re-injury Cross sectional area of injury (% of total cross sectional area) Re-injury (n=4): 87% [95% CI: 68%, 100%] No re-injury (n=25): 54% [95% CI: 43%, 65%] Silder et al. (2013) J Orthop Sports Phys Ther
- 26. UW Neuromuscular Biomechanics Lab Edema Drainagein Fascial Plane Edema and hemorrhage can extend into the fascial plane Over time, fascial drainage can lengthen the craniocaudal extent of injury and result in MRI measurements longer than the actual muscle/tendon damage Silder et al. (2013) J Orthop Sports Phys Ther
- 27. UW Neuromuscular Biomechanics Lab Post-Rehab StrengthDeficit 0 0.2 0.4 0.6 0.8 1 1.2 1.4 1.6 Return-to-Sport 6-month F/U KneeFlexionPeakTorque (Nm/kg) Injured Limb Non-injured Limb * ~10% deficit in peak torque between limbs at time to return to sport No deficit present at 6 month F/U Sanfilippo et al. (2013) Med Sci Sports Exerc
- 28. UW Neuromuscular Biomechanics Lab Persistent StrengthDeficits Sanfilippo et al. (2013) Med Sci Sports Exerc Silder et al. (2013) J Orthop Sports Phys Ther long short Hamstring Length Strength deficits pronounced at long muscle lengths Shift in angle of peak torque occurred in both limbs despite only one limb displaying scar tissue Neuromuscular deficit at return to sport Likely accounts for strength loss and shift in angle of peak torque
- 29. UW Neuromuscular Biomechanics Lab Summary Persistentscar tissue and weakness alter muscle-tendon dynamics Reduced displacement adjacent to injury site Increased strain At return to sport On average, 20% of muscle shows evidence of injury Clear evidence of scar tissue formation On average, 10% strength deficit At 6 months after return to sport: No remaining edema or signs of injury Considerable scar tissue formation Bilaterally equal strength Consideration of neuromuscular deficits: May be present during initial period of return to sport secondary to edema
- 30. UW Neuromuscular Biomechanics Lab Acknowledgements Collaborators Amy Silder, PhD Liz Chumanov, PhD, DPT Jen Sanfilippo, MS, LAT Darryl Thelen, PhD Christopher Westphal, MS Marc Sherry, DPT, LAT Mike Tuite, MD Steve Swanson, MS Thomas Best, MD, PhD Funding Aircast Foundation NFL Charities NIH AR056201 NIH 1UL1RR025011
- 31. UW Neuromuscular Biomechanics Lab Thank You- Gracias Madison, WI, USA