Clinical findings just after return to play predict
hamstring re-injury, but baseline MRI findings do not
hamstring re-injury, but baseline MRI findings do not
De Vos RJ, Reurink G, Goudswaard GJ,
Moen MH, Weir A, Tol JL. Br J Sports Med.
ePub 18 July 2014. doi:10.1136/bjsports-2014-093737.
Moen MH, Weir A, Tol JL. Br J Sports Med.
ePub 18 July 2014. doi:10.1136/bjsports-2014-093737.
Take Home Message: Key
predictors of hamstring re-injury are higher number of previous hamstring
injuries, more degrees of active knee extension deficit, isometric knee flexion
force deficit at 15°, and the presence of localized discomfort on posterior thigh
palpation just after return to play (RTP).
predictors of hamstring re-injury are higher number of previous hamstring
injuries, more degrees of active knee extension deficit, isometric knee flexion
force deficit at 15°, and the presence of localized discomfort on posterior thigh
palpation just after return to play (RTP).
There
are no specific guidelines regarding return to play (RTP) after a hamstring
injury. Despite using imaging techniques and agility and stabilization
exercises for treatment, re-injury rates remain a problem and increase the
rehabilitation period. De Vos and colleagues investigated the association
between clinical and imaging findings at baseline and clinical tests performed
after RTP to identify factors associated with re-injury following initial
hamstring injury. Eighty participants (age 18-50 years) were diagnosed with a
hamstring injury by one of six sports medicine physicians using both clinical evaluation
and magnetic resonance imaging (MRI) performed within 5 days of initial injury.
As part of the procedures, all participants completed a rehabilitation program
consisting of progressive agility and trunk stabilization exercises. The
clinical tests performed during initial diagnosis were also performed just
after RTP. These tests included hamstring flexibility, strength testing, and
muscle palpation. Participants reported possible hamstring re-injuries to the
study team and the lead investigator conducted a phone interview to confirm the
presence of a hamstring re-injury. The study team also asked the participants
about any possible re-injuries at a 6-month and 12-month follow-up visit. Sixty-four
of the eighty participants were included in the final analysis; 17 (27%) reported
a hamstring re-injury that occurred at a median 100 days after RTP. Four
specific factors were associated with re-injury, including 1) the number of
previous hamstring injuries (33% increased risk per number of previous
hamstring injury), 2) degrees of active knee extension deficit (13% increased
risk per degree), 3) isometric knee flexion force deficit at 15° (4% increased risk per measure of
force in Newtons), and 4) the presence of localized discomfort on posterior
thigh palpation just after RTP. The MRI findings showed 89% of clinically recovered
hamstring injuries had increased intramuscular signal intensity, but the re-injury
rate was too small to discriminate the findings as a predictor for re-injury.
In conclusion, the weak association of MRI results after RTP emphasizes that
clinical and functional tests are better predictors of hamstring re-injury than
an MRI just after RTP.
are no specific guidelines regarding return to play (RTP) after a hamstring
injury. Despite using imaging techniques and agility and stabilization
exercises for treatment, re-injury rates remain a problem and increase the
rehabilitation period. De Vos and colleagues investigated the association
between clinical and imaging findings at baseline and clinical tests performed
after RTP to identify factors associated with re-injury following initial
hamstring injury. Eighty participants (age 18-50 years) were diagnosed with a
hamstring injury by one of six sports medicine physicians using both clinical evaluation
and magnetic resonance imaging (MRI) performed within 5 days of initial injury.
As part of the procedures, all participants completed a rehabilitation program
consisting of progressive agility and trunk stabilization exercises. The
clinical tests performed during initial diagnosis were also performed just
after RTP. These tests included hamstring flexibility, strength testing, and
muscle palpation. Participants reported possible hamstring re-injuries to the
study team and the lead investigator conducted a phone interview to confirm the
presence of a hamstring re-injury. The study team also asked the participants
about any possible re-injuries at a 6-month and 12-month follow-up visit. Sixty-four
of the eighty participants were included in the final analysis; 17 (27%) reported
a hamstring re-injury that occurred at a median 100 days after RTP. Four
specific factors were associated with re-injury, including 1) the number of
previous hamstring injuries (33% increased risk per number of previous
hamstring injury), 2) degrees of active knee extension deficit (13% increased
risk per degree), 3) isometric knee flexion force deficit at 15° (4% increased risk per measure of
force in Newtons), and 4) the presence of localized discomfort on posterior
thigh palpation just after RTP. The MRI findings showed 89% of clinically recovered
hamstring injuries had increased intramuscular signal intensity, but the re-injury
rate was too small to discriminate the findings as a predictor for re-injury.
In conclusion, the weak association of MRI results after RTP emphasizes that
clinical and functional tests are better predictors of hamstring re-injury than
an MRI just after RTP.
Clinical
findings combined with a history of previous hamstring injuries were
significant predictors of re-injury of the hamstring within one year after the
athlete returned to play. Hamstring strains take time to heal so the
rehabilitation process must be carefully observed. Functional testing may be the
best way to determine if the hamstring is healed and if there is a chance of
reoccurrence. Functional testing may be the better and safer route to predict
re-injury of a hamstring strain over MRIs. Key predictors of hamstring
re-injury were decreased isometric knee flexion, decreased knee extension, and
tenderness with palpation of the hamstring muscles after return to play. The
baseline MRIs of the hamstring injury showed no significance in predicting
re-injury of the hamstring once the participant returned to play. If the re-injury
predictors in this study are implemented to clinical practice, athletes that
demonstrate the positive functional or clinical findings once they RTP may be more
likely to suffer subsequent injury. The findings of this study can also help to
identify rehabilitation and injury prevention strategies for hamstring
re-injury, by addressing the deficits reported in this study. Hence, we need to
keep sure we monitor the 3 key risk factors that we can modify (active knee
extension deficit, isometric knee flexion force deficit, and localized
tenderness), incorporate reducing these into our treatment goals, and reassess
them prior to RTP.
findings combined with a history of previous hamstring injuries were
significant predictors of re-injury of the hamstring within one year after the
athlete returned to play. Hamstring strains take time to heal so the
rehabilitation process must be carefully observed. Functional testing may be the
best way to determine if the hamstring is healed and if there is a chance of
reoccurrence. Functional testing may be the better and safer route to predict
re-injury of a hamstring strain over MRIs. Key predictors of hamstring
re-injury were decreased isometric knee flexion, decreased knee extension, and
tenderness with palpation of the hamstring muscles after return to play. The
baseline MRIs of the hamstring injury showed no significance in predicting
re-injury of the hamstring once the participant returned to play. If the re-injury
predictors in this study are implemented to clinical practice, athletes that
demonstrate the positive functional or clinical findings once they RTP may be more
likely to suffer subsequent injury. The findings of this study can also help to
identify rehabilitation and injury prevention strategies for hamstring
re-injury, by addressing the deficits reported in this study. Hence, we need to
keep sure we monitor the 3 key risk factors that we can modify (active knee
extension deficit, isometric knee flexion force deficit, and localized
tenderness), incorporate reducing these into our treatment goals, and reassess
them prior to RTP.
Questions for Discussion: What are examples of different rehabilitation programs that might
focus more on the recovery of the clinical findings that are associated with
re-injury? What kind of training programs can be utilized by high-risk athletes
to prevent hamstring re-injury?
focus more on the recovery of the clinical findings that are associated with
re-injury? What kind of training programs can be utilized by high-risk athletes
to prevent hamstring re-injury?
Written
by: Samantha Sisson, Grace Brooks
by: Samantha Sisson, Grace Brooks
Reviewed
by: Kim Pritchard
by: Kim Pritchard
Related
Posts
Posts
De Vos, R., Reurink, G., Goudswaard, G., Moen, M., Weir, A., & Tol, J. (2014). Clinical findings just after return to play predict hamstring re-injury, but baseline MRI findings do not British Journal of Sports Medicine, 48 (18), 1377-1384 DOI: 10.1136/bjsports-2014-093737
Regarding "functional testing may be the better and safer route", what are we proposing as the best functional test(s)? The article I reference below looked at single leg hamstring bridge (SLHB). Thoughts?Br J Sports Med doi:10.1136/bjsports-2013-092356
Original article
The predictive validity of a single leg bridge test for hamstring injuries in Australian Rules Football Players
Grant Freckleton1, Jill Cook2, Tania Pizzari1
Regarding the statement: "functional testing may be the best and safer route to predict re-injury". what shall wee propose as the best functional test(s)? The authors below looked at single leg hamstring bridge (SLHB). Thoughts?The predictive validity of a single leg bridge test for hamstring injuries in Australian Rules Football Players
Grant Freckleton, Jill Cook and Tania Pizzari
Br J Sports Med 2014 48: 713-717 originally published online August 5, 2013
Hi Rose:
Thanks for the comment. I agree the single leg hamstring bridge has potential as a screening tool. For reinjury I think we also need to assess lingering point tenderness strength deficits, and limited knee extension. I suspect a lot of the emphasis will eventually be placed on hamstring strength and activation. We'll need to see more studies to really highlight the best predictors in various populations and age groups. Then the question is what do we do about this. I wonder if our injury prevention programs are sufficient or if they could be easily modified to help reduce the risk of hamstring injuries.
This article suggested a very good rerun to play functional test that has a high potential of determining if the player is healed enough for play. Single leg hamstring bridge assesses the hamstring strength while the hip and knee are in a functional position. During athletic participation the hip is extended through movements while the knee is flexed. Doing single leg hamstring bridge assesses the individual leg or hamstring that is injured; therefore the athlete cannot favor the injured hamstring with the uninjured leg. This functional test showed that hamstrings that were strained during the ongoing season were weaker than uninjured hamstring strings. The single leg hamstring bridge is a test that looks at endurance and strength of an injured hamstring, which can be used to asses if the athlete is ready to return to play.[1] Irregular or poor muscle strength of the injured hamstring is a risk factor for a reoccurrence hamstring strain. Thus, muscle strength of the previously injured hamstring must be assessed during functional movements to determine if there is a strength deficiency. Other functional tests that can be used for rehabilitation and for return to play are progressive agility tests and trunk stabilization.[2] These tests are shown to help prevent re-injury of the hamstring on returned to play. Recently injured tissues are weak and can be reinjured with stresses in the sagittal plane. Therefore agility training in the frontal plane can strengthen without lengthening and overusing the healing tissues.2 If the tissues heal properly then the chance of re-injury is decreased. Performing agility and trunk stabilization is important to maintain range of motion at the hip and pelvis and reduce atrophy. The trunk stabilization and hamstring length can be assessed through windmills, prone bridges, and side planks. Low to moderate intensity sidestepping and grapevine stepping were good functional tests for hamstring return to play.[2] Jogging in place at a fast speed was also used as a functional test to return to play since many acute hamstring stains are sustained during sprinting activities.2 Single leg bridges as well as sprinting combined with side to side agility and core stabilization testing is best to determine if there is full mobility of the hip and knee, full muscle strength and length of the injured hamstring compared to the healthy leg.[1,2]
1. Freckleton G, Cook J, Pizzari T. The predictive validity of the single leg bridge test for hamstring injuries in australian rules football players. British J Sports Med. 2014;48(8):1-5. https://eds.b.ebscohost.com.suproxy.su.edu/ehost/detail/ detail?vid=3&sid=69673831-cb1a-46bb-858c 0c3fbac54af1%40sessionmgr 198&hid=112&bdata=JkF1dGhUeXBlPWlwLHVybCxjb29raWUmc2l0ZT1laG9zdC1saXZl#db=s3h&AN=95315130. Accessed November 10, 2014.
2. Sherry M, Best T. A comparison of 2 rehabilitation programs in the treatment of acute hamstring strains. J Orthopaedic & Sports Physical Therapy. 2004;34(3):116-125. https://eds.b.ebscohost.com.suproxy.su.edu/ehost/detail/detail?vid
=12&sid=69673831-cb1a-46bb-858c-0c3fbac54af1%40sessionmgr198&hid
=112&bdata=JkF1dGhUeXBlPWlwLHVybCxjb29raWUmc2l0ZT1laG9zdC1saXZl#db=s3h&AN=SPHS-937449. Accessed November 10, 2014.
This article stuck out to me because with our great advances in technology, it is easy for patients to rely on imaging to assure they are structurally healthy enough to return to play. Although imaging is an important component of returning to play, this study demonstrates the importance of our knowledge as clinicians to treat sports medicine as an "art", and not just as a science. Ultimately, patients need our expertise and experience dealing with certain injuries to give them the best opportunity to successfully return to play. I enjoyed reading this article because it gives all readers a reminder that our evaluation skills and ability to identify even the smallest differences can make a great impact on the success of our patients in the future.
Thanks Kyle! These days it is so easy to get an MRI or ultrasound but I agree that we can never underestimate the value of a comprehensive physical exam.