1. Hamstring Tear Dr Riaan Barnard MB,ChB BSc Hons M Sport Med (3’rd year)

2. Biggest set of “Hams” in SA !

3. Case History Mr Chris Howes, Triathlon Athlete, aged 45, tried a dry Slalom take-off on 22/12/10Mr Chris Howes, Triathlon Athlete, aged 45, tried a dry Slalom take-off on 22/12/10 Slipped, ended in “splits”, felt sharp pain mid-upper section L hamstring, feeling of “something shearing off”Slipped, ended in “splits”, felt sharp pain mid-upper section L hamstring, feeling of “something shearing off” Immediately couldn’t walk – limped backImmediately couldn’t walk – limped back Took some NSAIDs, ice & pain meds, Kinesio Tape and “hoppled along” rest of vacationTook some NSAIDs, ice & pain meds, Kinesio Tape and “hoppled along” rest of vacation Saw Dr v Hagen on 3/1/11 for sonarSaw Dr v Hagen on 3/1/11 for sonar

4. Sonar Results ?? Showed very large, hypoechoic area of 5,5 x 4,5cm in mid-upper Biceps Femoris section LShowed very large, hypoechoic area of 5,5 x 4,5cm in mid-upper Biceps Femoris section L Diagnoses of Grade II – III Hamstring Tear was madeDiagnoses of Grade II – III Hamstring Tear was made Previous History:Previous History: No previous hamstring tears / injuryNo previous hamstring tears / injury Lower back injury last 6/12 – saw Chiro regularly for manipulationsLower back injury last 6/12 – saw Chiro regularly for manipulations

5. Clinical Examination Large bruised area whole hamstring area with extravasation into popliteal fossaLarge bruised area whole hamstring area with extravasation into popliteal fossa TP’s palpable surrounding area & GluteusTP’s palpable surrounding area & Gluteus Ext knee - resulting pain in hamstring areaExt knee - resulting pain in hamstring area Hamstring muscle stretch test positiveHamstring muscle stretch test positive Eccentric hamstring contraction pain ++Eccentric hamstring contraction pain ++ No neurological deficit / neg Slump testNo neurological deficit / neg Slump test

6. Diff Diagnoses / Spec Investigations Grade II Hamstring Tear – Biceps Femoris + possible SemimembranosusGrade II Hamstring Tear – Biceps Femoris + possible Semimembranosus Caused by sudden forceful eccentric stretching, possible predisposing factor large hamstring muscle, not warmed up by stretching, possible stiffness due to contributing back problem?Caused by sudden forceful eccentric stretching, possible predisposing factor large hamstring muscle, not warmed up by stretching, possible stiffness due to contributing back problem? Serial Sonars were done with each subsequent PRP injection follow-upsSerial Sonars were done with each subsequent PRP injection follow-ups

7. 3-Stage Summary Personal / Psychological:Personal / Psychological: Not being able to compete in the 2011 Iron Man Series Social / Contextual: Felt he was letting his fiancé down, as he is her training partner for Iron Man

8. Plan & Progression Consulted me on 5/1 for PRP injection. Sonar directed 5cc volume injected into hypoechoic area.Consulted me on 5/1 for PRP injection. Sonar directed 5cc volume injected into hypoechoic area. Initiated straight leg hamstring stretches + active knee- extensions to point of pain. Ice and Tramacet prn – no NSAIDs !Initiated straight leg hamstring stretches + active knee- extensions to point of pain. Ice and Tramacet prn – no NSAIDs ! Sent to Chiro for Lumbo-sacral hypo-mobile segment to be manipulated, as well as soft tissue treatment, dry needling for surrounding TPsSent to Chiro for Lumbo-sacral hypo-mobile segment to be manipulated, as well as soft tissue treatment, dry needling for surrounding TPs On 8+9/1 swimming slowly in pool + continued stretching & strengthening exercisesOn 8+9/1 swimming slowly in pool + continued stretching & strengthening exercises On 14/1 did slow 2-3km jog the morning – pain free. Later that afternoon PRP nr 2. Hypoechoic area shrunk to 3,5 x 2,5cm with new tissue formation visibleOn 14/1 did slow 2-3km jog the morning – pain free. Later that afternoon PRP nr 2. Hypoechoic area shrunk to 3,5 x 2,5cm with new tissue formation visible

9. Progression continued… On 15/1 did slow 100km cycling race – pain freeOn 15/1 did slow 100km cycling race – pain free On 21/1 did 10km run – pain freeOn 21/1 did 10km run – pain free Last PRP nr 3 injected on 26/1 – hypoechoic area shrunk to 1,5 x 0,5 cmLast PRP nr 3 injected on 26/1 – hypoechoic area shrunk to 1,5 x 0,5 cm Did Half-Iron Man in East Londen on 29/1. Strapped the leg with Kinesio Tape and finished the race in better time than previous year ! Qualified for Iron Man April 2011Did Half-Iron Man in East Londen on 29/1. Strapped the leg with Kinesio Tape and finished the race in better time than previous year ! Qualified for Iron Man April 2011 What assisted a lot in this case, was the athlete’s background on rehab of injuries. It was thus easy to give him a copy of B&K pg 453 – Progressive Running Protocol and the Criteria for RTS to be followedWhat assisted a lot in this case, was the athlete’s background on rehab of injuries. It was thus easy to give him a copy of B&K pg 453 – Progressive Running Protocol and the Criteria for RTS to be followed

10. Sonar guided PRP injections

11. Continued…

12. Discussion Well described chapter in B&K pg 443-453Well described chapter in B&K pg 443-453 Epidemiology & Biomechanics of Injury : Sprinters, hurdlers, long jumpers, football players and dancersSprinters, hurdlers, long jumpers, football players and dancers Most common in sports high-speed running & kicking – biceps femoris most common injury. Athletes immediately stop with injuryMost common in sports high-speed running & kicking – biceps femoris most common injury. Athletes immediately stop with injury In dancers slow stretch movement at the end of range of movement (front & side splits) causes 87% cases of prox tendon of semimembranosus. Dancers are often able to continue dancing immediately after the injuryIn dancers slow stretch movement at the end of range of movement (front & side splits) causes 87% cases of prox tendon of semimembranosus. Dancers are often able to continue dancing immediately after the injury

13. Predisposing Factors to Injury Intrinsic Factors: Extrinsic Factors:Intrinsic Factors: Extrinsic Factors: These include -Age - Warm-up -Previous Injury - Fatigue -Race - Fitness Level -Flexibility - Training Modalities -Strength -Neuromyofascial -Lumbopelvic Stability -Joint Dysfunction

14. Review Article: Mann et al Three groups of Hamstring Injuries: 1.Proximal affecting common hamstring origin. Divided into 3 categories: - Tendon injury with full detachment ischium, found mostly in adults - Tendon injury with full detachment ischium, found mostly in adults - Partial tears & overuse micro traumatic tendon tears in adults & children - Partial tears & overuse micro traumatic tendon tears in adults & children - Apophyseial overuse or acute damage with or without avulsion, mainly in children - Apophyseial overuse or acute damage with or without avulsion, mainly in children 2.Central hamstring injuries of muscle bellies 3.Distal injuries affecting distal tendon or tendon insertions

15. Proximal Injuries Proximity of sciatic nerve important – oedema & inflammation lead to irritation, leading to false impression of spinal nerve root compressionProximity of sciatic nerve important – oedema & inflammation lead to irritation, leading to false impression of spinal nerve root compression Thus strong argument exists to reinsert disrupted prox hamstring tendon to origin on ischium, both to regain function and preserve sciatic nerve from later damageThus strong argument exists to reinsert disrupted prox hamstring tendon to origin on ischium, both to regain function and preserve sciatic nerve from later damage 3 Stages of Apophyseal damage: apophysiolysis, avulsion and non-united avulsion fracture3 Stages of Apophyseal damage: apophysiolysis, avulsion and non-united avulsion fracture Union in widely displaced avulsion require 1-2 yrs. Avulsion > 2cm has common non-union and surgical repair should be consideredUnion in widely displaced avulsion require 1-2 yrs. Avulsion > 2cm has common non-union and surgical repair should be considered

16. Central Hamstring Injuries Theories:Theories: - Type II muscle fibers responsible for explosive force, more abundant in hamstrings than quads - Type II muscle fibers responsible for explosive force, more abundant in hamstrings than quads - All hamstring muscles innervated by tibial branch of sciatic nerve, except short head biceps innervated by peroneal branch of sciatic nerve – leads to forceful, uncoordinated contractions, or simultaneous contraction of hamstrings and quads

17. Brunet & Hontas’ Classification Grade I:Grade I: Small area, little haemorrhage and no structural damage Small area, little haemorrhage and no structural damage Grade II:Grade II: Felt “pop” or tear, immediate function loss, swelling, palpable painful mass, definitive structural damage Felt “pop” or tear, immediate function loss, swelling, palpable painful mass, definitive structural damage Grade III:Grade III: Complete tear, mass of palpable muscle, mass retracts on muscle activation, defect seen best at 2-3 weeks Complete tear, mass of palpable muscle, mass retracts on muscle activation, defect seen best at 2-3 weeks

18. Distal Injuries More frequently the tear takes place in the distal insertion of the Biceps FemorisMore frequently the tear takes place in the distal insertion of the Biceps Femoris Semimembranosus distal tendon is rarely rupturedSemimembranosus distal tendon is rarely ruptured Most full ruptures should be repaired at an early stage, followed by 5 weeks of cast immobilisationMost full ruptures should be repaired at an early stage, followed by 5 weeks of cast immobilisation Semitendinoses tears should be left alone and not surgically repaired – little morbidity is caused by its absence when used as graft in ACL repairsSemitendinoses tears should be left alone and not surgically repaired – little morbidity is caused by its absence when used as graft in ACL repairs

19. Take Home Message / Learning Experience Using PRP sonar guided injections work very well in acute muscle tears of the hamstring muscles and dramatically reduces return-to-play time !!Using PRP sonar guided injections work very well in acute muscle tears of the hamstring muscles and dramatically reduces return-to-play time !!

20. References 1.Brukner, P; Khan, K. Clinical Sports Medicine, Third Edition. 2008. pg 443 2.Deleget, A. Overview of Thigh Injuries in Dance. Journal of Dance Medicine & Science. 2010, vol 14(3), pg 97-102. 3.Koulouris, G; Connell, D. Imaging of Hamstring Injuries: Therapeutic Implications. Eur Radiol (2006) 16: 1478-1487 4.Mann, G; Shabat, S; Friedman, A; et al. Hamstring Injuries. Orthopedics/ORTHOsupersite.com 5.Wehling, P; Moser, C; Frisbie, D; et al. Autologous Conditioned Serum in the Treatment of Orthopedic Disease. Biodrugs 2007: 21(5): 323-332