July Journal Club Case

[omikutin]

Happy July Fourth!

Subjective:
42 yo male with proximal hip pain (R). Patient is training for a marathon and was sprinting then experienced a sharp local right proximal hamstring pain. He stopped running and limped home. No swelling or discoloration, numbness/ tingling. PMH: reports history of tight hamstrings, hurt B hamstrings from running a 5k last year (less intense but same pain).
Goals: Run a marathon in 5 weeks.

Aggravating Factors: walking, stairs, jogging, prolonged sitting, tying shoes/ taking them off, pain with going uphill
Relieving Factors: ice, staying away from aggravating factors

Objective:
Gait: mild antalgic with trendelenberg, decreased hip extension
Functional screen: Increased weight on L LE during squats with minor pain, unable to R SL squat
AROM: Passive SLR: R 68, L 80, lumbar cleared
Strength: Hip ABD: 4/5 L, 4/5 R, Hip Extension: 4/5 L, R 4/5, Knee flexion: L 4/5, R 3/5
Special Test: + Thomas (rectus femoris/ iliopsoas, IT band), SLR (60), Pain with resisted knee flexion in prone, Swing (limited hip extension, increased anterior pelvic tilt with pain at terminal swing), – SLUMP
Palpation: pain with proximal right hamstring, lateral hamstring pain and hypertonic (bicep femoris) distal 5 inches

Severity: moderate, reports fear of pain when returning to jogging, pain with walking
Irritability: moderate, relief with decreased aggravating activities, immediate pain with walking up stairs

Primary hypothesis: Proximal Hamstring Strain

Treatment:
Education: Education of shortening strides when walking, underlying pathology, decrease forward lean during running
Manual Therapy: Proximal hamstring soft tissue, hip distraction
Exercise Prescription
Focused on hamstring flexibility
Stability exercises for strength and trunk/ pelvis stability
Strength training

Day 1:
Evaluation/ education
Supine knee flexion/ extension

Day 2:
Subjective: Have not been jogging and no complaints of pain.
SLR 60 pain end range
Bridging, single leg bent-knee bridge
Supine knee flexion/ extension
Diver (check out the article)
Glider- only UE (check out the article)
Reassess: SLR 65 pain end range

PICO
Would a patient with a proximal hamstring strain benefit from a lengthening rehab program as compared to a traditional program shorten the time needing to return to running?

Questions:
Is there anything you would have done differently, if so what? What kinds of treatment have you found beneficial with this population?

Education! I made sure to communicate it’s his second hamstring strain and reoccurrence rate is very high. A mid hamstring strain takes about 12-15 weeks and the proximal hamstring takes around 35-45 weeks. Do you think my patient’s goal is achievable or is he a little too ambitious?

Would a patient with a proximal hamstring strain benefit from a lengthening rehab program as compared to a traditional program shorten the time needing to return to running?

Would you have used another test/ retest for this, such as the Askling or something more functional?

Most of the injuries occurred during the end of the training session. What is something you can do to help limit that injury from happening?

According to this article, why do you think the jumpers had increased days of return to sport as compared to the sprinters?

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[Kyle Feldman]

I have used this article with two runners now after a hamstring strain and it worked very well
I think the three exercises were simple but challenging enough for my weekend worrier patients.

Look forward to hearing your outcome

Kyle

[omikutin]

I emailed this article to my patient. He enjoyed the pictures!

Another reason why I chose this article is because one of my colleagues told me she typically goes for a lengthening protocol. Her rational was “it uses more muscle fibers”. It made me further look into why and what type of lengthening protocols would be best.

[Laura Thornton]

Thanks for sharing Oksana! Looking forward to discussing this study at journal club. I think it’s great that you are trying to be as specific as possible with the type of rehabilitation program for him and adding in trunk/pelvis stability training.

You mentioned that you provided him with a verbal cueing of decreasing forward lean during running. What is your rationale for giving him this cue?

I think mapping out a return to run plan would also be an important component to discuss with the patient. The article by Heiderscheit et al from 2010 talks about progressions from stage to stage for hamstring strains, with criteria to progress to return to sport. Without knowing the exact location and extent of the injury, this could help with planning out what he can expect through recovery and keep you guys on the same page. Have you guys discussed a plan for this yet?

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[omikutin]

My rational for the cue was what during running could possibly decreased the amount of strain on his hamstring. I didn’t say stand straight up, but decreased the amount of forward lean that he had. Staying away from training on hills or extra stress on his hamstring might be helpful. No matter what, he was going to run.. I chose the lesser of the evils.

Running: in the beginning he was afraid of running, however I wanted to get him jogging early. Around the third day I had him jog with shorter strides. He was happy getting back to running. I had a walk:run balance starting with walking 3 min and jog 2 min and I progressed as necessary.

Thanks for attaching an article! I love the rotation dumbbell exercises. I’m attaching another article that I found helpful.

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[Nick Law]

Thank you for posting! A couple of questions and thoughts:

– How long ago was the original injury? Antalgia with regular gait, inability to single leg squat, immediate pain with stair negotiation/resisted testing make me think that his injury is still fairly acute/subacute. In light of this, I would probably be cautious and stay away from eccentric or “lengthening” exercises in this stage of condition; that would seem to be too much load for the state his tissues seem to be in. Agility exercise, hip and trunk strengthening, manual therapy to prevent excessive scar immobility would certainly make sense to me. However, I know you have already tried the “diver” and so I am curious to hear how it went. Additionally, in this study they started such lengthening exercises 5 days after the initial injury, and noted that no exercise was allowed that caused pain. In my clinical experience those certainly seem at odds with each other, so I am not exactly sure how it worked out.

– Immediate pain with stairs, inability to perform single leg squat, and trying to run a marathon in 5 weeks seems like a very, very loft and likely unreasonable goal. I think you are very wise to give him specific time frames on how long it generally takes to recover from an injury such as his so that he can reform his expectations.

– I believe that the Askling H test is used to help make return to sport decisions late in the rehab process. That is, once SLR/resisted testing/functional movements are all WNL, THEN I would use the Askling active hamstring flexibility test.

– I wonder if “maxing out” on the last repetition of repeat sprints is not a good idea with regards to hamstring preservation. That looks like that may have been the mechanism in many of these athletes.

– I like the new article from Reiman on hamstring tendinopathy, however I would just be sure to draw attention that proximal hamstring tendinopathy and proximal hamstring strain are distinct conditions. I do think that there are a number of similarities in treatment approach, but I do think there is value in recognizing them as similar but distinct entities.

[omikutin]

Isn’t that article crazy!?! I saw that they started within 5 days of the initial onset. Do you think they started earlier due because the article was performed on elite athletes? My patient injured himself the weekend before and came in the following Tues or Wed. His second appointment was a week later (scheduling that worked best for him). He wasn’t limping the second visit. He was taking it “easy” and working on his current HEP. He also had no pain and therefore I proceeded with the lengthening program.

You do bring up a good point on PHT vs. proximal hamstring strain. How would you approach them differently treatment wise?

[Laura Thornton]

Good point between tendinopathy vs. strain. There are certainly overlap between both, but there’s a few different important aspects I would consider:

– Lack of inflammatory process with tendinopathy vs. acute tear/strain of hamstring muscle belly including edema, hemorrhage, etc. I would think that strengthening the tendon to allow greater tolerance to load vs. promoting remodeling of muscle fibers would need to be kept in mind.

– Load, Load, Load for tendinopathy. Certainly strengthening is key for both conditions, but I wouldn’t tend do perform manual therapy and other aspects of care that I might add for a strain/tear.

Aspects that overlap: assessment of neurodynamic involvement, agility training, lumbopelvic stability, and progression of resistance exercises incorporating eccentric lengthening when appropriate and pain-free.

[ABengtsson]

Thanks for posting Oksana!

In regards to PHT vs. strain I’d first want to know whether PHT is in the reactive, dysrepair or degenerative stage and treat accordingly (based on VOMPTI ankle lectures and running med conference); if it’s a strain/muscular pathology, I’d try to be as specific as to what type of m. pathology it is. The below article has been very helpful for me to distinguish between the types, how to approach them and what to expect in regards to prognosis. Also, one of the authors was interviewed for a BJSM podcast a few months back.

I’ve used lengthening exercises early on with several pts if tolerated, but with high irritability, I’ve also used prolonged isometrics with progressively lengthened position of the muscle(s), similar to tendinopathy pts.
It would be interesting to see how this study would play out in a population not consisting of elite athletes. That being said, as long as the exercises are performed in a pain free range, I don’t think that should make a huge difference. I’d just expect significantly different levels of performance depending on the pt.

I’m also wondering how the lengthening protocol would work for pts with stretching type injuries (all subjects in L-protocol were springing type).

In regards to higher frequency of injury towards the end of the sessions, I would think that would be an issue to be addressed with the coaches (in the study) and with pts (if applicable). There have been some studies recently regarding training intensity and although injury prediction is a pretty controversial topic, it’s a good start. (see below and Gabbett also has a BJSM podcast worth checking out).

The studies Askling did were with sprinters/jumpers and soccer players, so I don’t know how that would translate into long distance running. Also, the soccer players did better in regards to return, likely due to the fact that they can avoid sprinting at max effort if need be -> possibly earlier return for long distance runners? Would be interesting to see how intensity vs. repetitive load differ in outcomes (if at all).

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[Nick Law]

Oksana – if there is no pain with exercise performance, exercise technique is acceptable, it doesn’t excessively exacerbate symptoms over the next 24-36 hours, then I would probably feel good about continuing with lengthening exercises as you have done.

I agree with Laura on aspects of tendinopathy vs. muscle injury. In general, I think that tendon injury tends to take longer to recover from (though of course depends on severity of injuries you are comparing). I might tend to be even more movement-analysis and correction oriented with a tendon issue vs. a muscle injury. Repetitive loading in an poor fashion seems more to be the culprit in the former, compared to “simple” overexertion in the other.

Great point on lengthening exercises in “stretch” injury patients, Alex. I am working with such a patient right now and they have yet to prove effective. Also, thanks for posting the article regarding terminology and classification of muscle injuries – seems to speak some clarity into confusing terminology at times.

[omikutin]

Laura- I completely agree with load load load for tendonopathy and strengthening for the strain injury. For the strain, I would also focus more on making sure we stay away from pain while the tendonopathy some pain might be ok.

When it comes to diagnosing, I would try to focus on the MOI and when the injury happened. This will also hopefully guide me more towards prognosis.

Alex- You would pick a German article :). Thanks for posting it! It sounds like Mueller doesn’t like the term “strain”, but they use “tear” instead. It might be difficult communicating that to a patient.

I like your approach of using prolonged isometrics for irritable patients. This article brings up an interesting hypothesis about why the lengthening approach worked. “This limitation (C-protocol) at the long hamstring muscle lengths could lead to eccentric hamstring weakness and possibly hypertrophy of the short head of the bicep.” Have you ever noticed the short head working more compared to the long head when you did the prolonged isometrics? Or have you had good results and moved on (that would be neat if you noticed something)? I also COMPLETELY agree with addressing this issue with coaches!

Nick- What are some things you’ve done that have been beneficial for your stretch type injury? My patient did not have pain day two therefore I introduced the lengthening protocol. I may have introduced a little too much, but we had a goal and no pain limitations.

[Kristin Kelley]

Hey Oksana
you mention a “negative” slump but “SLR of 60 degrees” in your original exam notes. What do you mean by this and do you think you can totally rule out neurodynamic involvement in this case? The neural tissue in this area is SO closely related to the soft tissue that I’m wondering how much it was potentially affected during the MOI and/or how much it could actually be involved as the healing process occurs (especially if you’re considering using treatments inducing lengthening therex)? Can anyone weigh in on this component of his case and how they would factor it in so you’re not missing a valuable part of his rehab and return to sport?

[sewhitta]

Reading this case really makes me want to know more about this guys running history, level of experience, past race experience and current training program. Marathon runners and sprinters are two very different athletes. I would want him to describe or define the “sprint” that he states he did at the end of his run and reason for why he was doing a sprint, given he’s training for a marathon. Was this sprint a one-time thing? How often does he “sprint” and how long has he been training in this manner? It seems like there’s a possibility in a training error on his part. I feel like if your goal is to run a marathon, the risk vs. reward is too great to add “all out” sprints in your training regimen. In my opinion, this just substantially increases your risk of injury with minimal benefit when training for a marathon. I think this should be investigated more and addressed during treatment to prevent future injuries.

I agree with Nick: the injury is sub-acute and the tissue seems highly irritable and exercise prescription should be dictated by pain. There could be chance he could make it to the starting line of his marathon, if his training as been consistent up to this point, and if he avoids overloading his hamstring by sprinting.

[omikutin]

Kristin- Great point on neurodynamics! Thanks for pointing that out! My apologies, I could have been better to distinguish the SLR. His active SLR of 60 may be due to his hamstring lengthening and therefore putting stress on the tissue and the higher the leg is raised the more proximal tissue is stretched. Now, I could have done a much better job with the SLR and added cervical flexion or ankle DF to further rule out a serious neurodynamic component.

One of the exercises presented in this article works on flexibility as the patient does some sciatic glides (L-protocol). I can’t argue that muscle lengthening will not test the nerve but adding distal components (cx flexion, DF flexion) would point towards neuro.

Sean- That’s exactly what I asked him. Why were you doing sprints? He said he was cross training (swimming and biking) at least 3x a week, running long distances at least twice per week, and doing sprint and hill intervals once per week. The day he got injured he ran a good distance and then decided to do sprint intervals. Which he said wasn’t a smart idea.

He was never a runner but he decided he wanted to run a marathon in his hometown in Iowa and surprise his Mom. I talked to him about making sure he stayed away from sprints and hill workouts.

[ABengtsson]

Oksana – I did an internship at his clinic so I admit there is potential for bias.
I wouldn’t necessarily use that terminology with patients (depending on personality etc), but I think being more specific with classification will help in regards to treatment/POC and communication with other PTs and MDs.

To be honest, I never tried to distinguish b/w which one is working more and I’m not sure how I would, or that I could. Depending on the injured hamstring, I might modify positioning to affect muscle length of specific parts (i.e. bridge with slight tibial IR/ER etc.), but haven’t tried anything beyond that. From my understanding, the thing to keep in mind with the L-protocol is that early on scar tissue tolerates less tensile forces than the muscle and that’s why you’d want to keep it pain free, while still loading the muscle in the available range. I wonder if creating low level tensile forces would actually facilitate improved scar tissue formation, similar to benefits of axial load on bones.

Great point with the neurodynamics! Perhaps a reverse slump would tell you more since you’re already taking up the slack in the LEs and then adding C/S and T/S FLX. If positive, I’d be really interested in seeing how addressing that component changes his symptoms.

Sean – I don’t see a lot of runners… have you (or anybody else) worked with a lot of long distance runners who incorporate sprinting?

[Laura Thornton]

Alex >> I like Heiderschiet’s article talking about both the theories on effect of eccentrics on scar tissue development:

“An alternative explanation is that the use of early mobilization limits the residual adverse effects of scar tissue formed early in the remodeling process. Early mobilization has been shown to promote collagen penetration and orientation of the regenerating muscle fibers through the scar tissue, as well as re-capillarization of the injured area.”

And the effects in terms of the ability for the muscle to accept more tension due to a shift of the length-tension relationship:

“Scar tissue is stiffer than the contractile tissue it replaces, and thus may alter the muscle-tendon contraction mechanics. Specifically, a decrease in series compliance would shift peak force development to shorter musculotendon lengths. In noninjured subjects, the performance of controlled eccentric strength training exercises has been shown to facilitate a shift in peak force development to longer musculotendon lengths. Therefore, eccentric strength training following a hamstring injury may effectively restore optimum musculotendon length for active tension to normal, thereby reducing the risk of reinjury.”

[Laura Thornton]

I’m not sure if you would be able to rule out neurodynamic involvement yet, especially with the history of previous strains (with no treatment), possible scar tissue, and close proximity of the structures. If unsure, I would perform a neuro exam too to be sure of any involvement of nerve injuries, and nice idea by Alex for the reverse Slump. If there is a component of neurodynamic involvement, and not addressed, I would think that it might affect overall pain levels, strength gains, and predisposition for further injury, therefore delaying recovery process and ability to progress through exercise program.

Does anyone recommend continuing to monitor SLR/Slump/neuro throughout the recovery process to ensure that scar tissue doesn’t affect nerve mobility?

[Nick Law]

I am very much in agreement with Sean’s pointing out the training errors contributing to this injury. Doing some mile repeats or something of the like would probably be fitting, however “sprints” certainly seems inappropriate if the goal is to run a marathon. Definitely smart to spot that and educate on appropriate and beneficial training.

I am not sure we can effectively, “rule out,” neurodynamics at this point; however, if reverse slump is negative and altering SLR straight leg raise with cervical flexion/ankle DF /hip ADD does not change his symptoms, I am not sure we can decisively rule it in at this point either. While a high percentage of patients have been shown to have neural mobility deficits with hamstring injuries, it is not all of them, and we do well not to bias ourselves into thinking something is there when clustering of tests are negative. All that to say: do some more neurodynamic testing as mentioned and treat what you find, not what you don’t find.

[sewhitta]

If he hasn’t already defined to you what he considers a “sprint” interval or repeat, I would definitely ask. This could mean something different to various types of athletes, or to novice or un-experienced athletes. To me, sprint repeats would be 100-110 yards all out sprints, followed by maybe a two minute rest break, repeating maybe 10 times. Very appropriate for a football player that maximally exerts themselves for 7 secs per play, followed by a rest break in the huddle. Not so appropriate for a long distance runner.

Go back to the three energy systems being used with activity: the Phoshagen system, Glycolysis (anaerobic) system and Aerobic system. Now, hill repeats for say 1-3 minutes at a time is appropriate to raise your anaerobic threshold to help you get over a steep hill. However, a 100 yard sprint for 15-20 secs doesn’t require much, if any, oxygen (Phosphagen system). Two different workouts, stressing two different systems for two very different activities.

Now, your guy may consider his sprint workout to be a high intensity interval track workout, performing repeats of 400 or 800 meters, at say a pace 30% faster than race pace, to improve strength and raise his anaerobic threshold. Or like he said, hill repeats for 1-3 minutes followed by an active rest back to aerobic. Very appropriate for a distance runner. I would definitely have him lay out and specify what he’s doing for his sprint workouts.

[Michael McMurray]

Great string of posts – sorry to be late into the chat, but I was busy in Scotland.

A few of these points have been made, but these are my main thoughts:
– When exactly was the injury relative to your Eval?
– All of your decision making is based on Clinical Reasoning through tissue injury principles, related to specific loading and assessment, time line, prognostic factors that we know determine return to play
– “Play” is different than return to Marathon running, regarding load on HS
– Why flexibility/lengthening early on – have an assessment that gives you info about where the tissue in the healing state (What might that be?)
– What are some of those prognostic factors in the literature that help determine extent of injury and help with return to “play” education/expectations?
– Primarily think about what angle of knee flexion resisted aggravated sxs (mid/end ROM – with IR or ER or neutral rotation)
– Why recommendation to avoid hills, and run more upright? – think about what those recommendations bio mechanically do to the HS?
– What decision making criterion did you use to advance graduated loading?
– I agree completely with Strain versus Tendinopathy; and that should guide your loading progression.

I will not be on the conference call tomorrow – so hopefully these points help facilitate some more discussion

Cheers

Eric

[omikutin]

Alex- I completely agree with getting as specific as possible. I also love the Gabbett article where it talks about training smarter not harder. I believe this is a GREAT communication tool. “Excessive and rapid increases in training loads are responsible for injuries”.

I remember learning how tensile forces significantly help improve scar tissue formation. I mean if there isn’t tensile loading then I could only imagine how much adhesion and lack of mobility would be present. Laura explains this perfectly! Thankfully the proximal hamstring has a general linear fiber presentation which makes me like the “diver/glider” exercise much more.

Neurodynamics- He tested negative on the SLUMP and SLR with an addition to distal mechanisms. My focus was not neurodynamic, but I believe monitoring those would me a good idea. Honestly, if we push the SLR/ SLUMP with all the distal factors, I will have symptoms. Granit- my patient would have slightly more of HIS symptoms with added ankle DF possibly due to lengthening the muscles, cervical flexion or trunk side bending did not change anything.

Training- He did at least 6-8 sets of 100 meter sprints with rest breaks. Sean you bring up a great point about training and increasing his aerobic and anaerobic threshold. I don’t think anaerobic is as vital as aerobic but he might need it if he’s trying to pass someone during the last stretch. His goal was to run a marathon and get there at least under 5 hours. He agreed sprinting should not be his focus during this training.

[omikutin]

My patient came in within a week of getting injured.

I completely agree that return to play / competitive intense workouts are very different than return to marathon running. I choose this article because I wanted my patient to return as quick and pain free as possible. This article focus on making sure the athlete was not limited to pain during exercise. Pain was also one of my guidelines when prescribing and progressing exercises. Askling’s specific protocol focused on the entire hamstring which is why I appreciated it. I didn’t have my patient do the general exercise protocol because it wasn’t functional for him.

There was no discoloration and his hamstring MMT was painful at his proximal hamstring. Does anyone know of a test that would be good for determining the tissue healing state? Prone knee flexion at 90 was painful and at 120 degrees was more painful. I should have tested it with IR and ER. Initially when my patient couldn’t do the single leg squat, I was a little worried which is why we stayed away from weight bearing exercises. Honestly, I thought 5 weeks and a marathon didn’t sound possible.

Prognostic factors: We’ve learned that if the proximal hamstring tendon is involved the prognosis is much longer. Askling points out that his athletes took around 30-40 days longer to heal if the PHT was involved. As well, my patient has injured his hamstrings previously which is why he is more likely to get injured again. Does anyone else have anything to add on prognostic factors?

Running: I recommend he be slightly more upright because I didn’t want there to be more tension on his hamstring with a forward trunk lean. Forward momentum is important but I didn’t want him to be too far forward. Any other thoughts?

[Myra Pumphrey]

Sorry I am also late to comment due to travel. Just a couple additional thoughts. Oksana, you noted that Slump was negative on exam, so I thought you examined this in detail. What were the specific findings? Also, you said that you treated with hip distraction. What were your clinical findings that influenced you to include this treatment technique?

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