Hamstring Strain Injuries - Aspetar Experience Nicol van Dyk & Philipp Jacobsen
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Presentation by Nicol van Dyk & Philipp Jacobsen at the Conference on New Sports Medicine Concepts in Handball 2015
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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
- 4. We needed some Handball expertise
- 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
- 7. “When can I play again?”
- 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
- 11. Initial Assessment • History • Mechanism • Pain • Past History • Gait • Palpation • Flexibility • Active Movement
- 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
- 14. Initial Assessment • History • Mechanism • Pain • Past History • Gait • Palpation • Flexibility • Active Movement
- 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
- 24. Discharge Criteria & Recommendations
- 25. Discharge Criteria & Recommendations
- 26. What we found Treatment Outcomes
- 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
- 28. Pain today Injury Mechanism Size of injury SLR Flexibility Strength Squatting Walking Running Bent leg bridge Neural involvement Injury Location HS ϴ Flexibility 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?
- 29. Regression Analysis “Not everything that counts can be counted, and not everything that can be counted counts.” Einstein/Cameron
- 30. • 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 √
- 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
- 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
- 34. Protocol & Daily Assessment
- 35. The Protocol • 3 Stage protocol • Set criteria to progress • Daily reassessment • On field Sport Specific Rehabilitation
- 36. Stage One Progression criteria: • Bike 2 X BW (Power) 5 min • Pain free single leg squat
- 37. Stage Two Progression criteria • Run >70% • SLR & HS Θ > 75%
- 38. Running Progression • Walk • Jog • Run • Triple extension • Late swing (“A drill”) • Direction change
- 39. Stage three Progression Criteria • 100% running • T-test completed • No strength deficit
- 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
- 42. Tools
- 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
- 49. Thank you
- 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
- 54. Range of Motion
- 55. T Test
Editor's Notes
- 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