Hamstring Injury-A Case Study
David Gryfe B.Sc., DC, DAc, FCCSS (c), RTP
Hamstring injuries are common among athletes particularly in activities requiring explosive bursts of extension force or an extreme range of hip flexion or abduction. Hamstring injuries are classified as strains ranging from grade I to III. Grade I equates to mild pain and swelling with no disruption of the musculotendinous unit and no change of strength or length of the muscle. Grade II is suggested by a moderate degree of each indicator and grade III involves a complete tear of the musculotendinous structure and severe degrees of pain, swelling and limitations of strength and length. In addition, a commonly held view of hamstring strains is that the closer the disruption lies to the origin at the ischial tuberosity the more likely it is to go on to chronicity. Hamstring injuries, therefore, range from a mild irritant resolving spontaneously to a debilitating, season altering condition.
A seventeen-year-old female dancer presented with a complaint of pain in the posterior left thigh of five weeks duration. She reported that the symptoms first appeared during a dance rehearsal when she rapidly raised her left leg into a high, overhead position (abduction and flexion). She experienced a popping sensation in the posterior thigh at that moment and the pain ensued immediately thereafter. She did not note any bruising in the posterior thigh or leg nor any significant swelling in the area subsequently. However, she did report a progressive loss of flexibility of the left hip with regard to straight-legged hip flexion and abduction, limited by pain, following the initial injury. Specifically she noted an inability to perform the splits with the left leg forward and the side splits position, whether on the ground, standing or airborne.
The patient also commented on a pre-existent snapping right hip on abduction and right lateral knee pain. She denied having any lower back pain. She was continuing to train for dance three times per week for a total of 15 hours careful to avoid positions which aggravated the pain.
Examination of the patient revealed a fit young woman with a mesomorphic build. Lumbar spine ranges of motion were grossly and segmentally normal except that on forward flexion the patient noted pain in the posterior left thigh as her fingertips approached the floor. An articular restriction of the left sacroiliac joint was noted. Supine straight leg raising revealed a range of 135 degrees or better on the right side and painful limitation at 70 degrees on the left. The pain was located in both the mid-belly of the medial hamstring and at the origin at the ischial tuberosity. Pain and weakness was elicited on resisted testing of the medial hamstring on the left.
Examination of the right hip revealed a repetitive “clunk” as the thigh was brought passively or actively from flexion and abduction down to neutral. No overt weakness or muscle shortening of the right psoas was evident. Tenderness to palpation was noted over the lateral collateral ligament of the knee and distal IT Band on the right side. Moderate forefoot overpronation was observed bilaterally in normal gait and accentuated in one-legged squatting.
A diagnosis of Grade II (2nd degree) left hamstring strain with secondary and contributory right psoas muscle dysfunction and right ITB syndrome was suggested and treatment was initiated to address the injuries and underlying dysfunction.
Light application of Trigenics® strengthening and lengthening procedures were utilized on the left hamstring, right psoas and ITB. At the conclusion of the first treatment the range of passive straight leg raising on the left side was improved from painful at 70 degrees to pain-free at 90 degrees. The patient also reported a significant reduction of tenderness at the lateral right knee. Treatment proceeded with progressive increases of the depth of application of Trigenics® procedures for two subsequent weeks at 2 visits per week. Trigenics® strengthening and lengthening as well as sacroiliac joint manipulation and interferential current were employed during which time a resolution of the right knee pain was achieved. A further 6 treatments at 2 visits per week resulted in considerably less snapping (clunking) of the right hip (NB this movement is integral to the patient’s normal functional range in dancing) and an increase in the left straight leg raise to 120 degrees. At the conclusion of 15 visits (which included a weaning period of 4 weeks of reduced frequency of treatment) a full restoration of function (including length and strength of the left hamstring equal to the right, elimination of pain in the right lateral knee and marked reduction of the audible clunk in the right hip) was achieved.
A further follow-up at six months will be conducted to determine the long-term outcome of this case.
Maintaining function and training through recovery from injuries presents a difficult problem for athletes and therapists. The ability to continue modified training without delaying recovery represents the best of both worlds. If the recovery can additionally be hastened from the natural history of the injury throughout modified training the benefits to the athletes are obvious.
At the initial presentation this 17 year-old dancer was at 5 weeks post injury and experiencing a progressive loss of function. Secondary areas of dysfunction were becoming symptomatic as compensatory neuromuscular mechanisms developed and fatigued. The risk of developing chronic adhesions and imbalances with long term sequelae is an ominous possibility.
Choosing an appropriate therapeutic modality to address the complex of dysfunction presented in this case requires careful attention to the details. Loss of muscular strength secondary to a partial tear is associated with neurological inhibition and the formation of adhesions. While muscle stripping procedures may address adhesions this treatment modality will not have a positive effect on the neurological component of the injury and may actually exacerbate the myofascial tear if applied too vigorously. Needle acupuncture may have a positive influence on both the neurological (e.g. the motor gate hypothesis) and mechanical (diapedesis, chemotaxis, and phagocytosis) aspects of the injury, but this option was not acceptable to the patient.
Trigenics® emerged as an obvious choice for the neuromuscular rehabilitation of this patient. Utilizing the effects of reciprocal inhibition a resetting of the muscle firing pattern can be achieved facilitating a neurologically mediated increase in strength (i.e. Trigenics® Strengthening). This procedure can be followed by the application of the inverse myotatic reflex which promotes the lengthening of the affected muscle (Trigenics® Lengthening). These procedures can be used progressively beginning at a level within patient tolerance and increasing the depth and extent of acutraction as healing advances. Trigenics® treatment can be combined with articular adjustments, Trigenics® home exercises, and standard isotonic strengthening as needed.
This case illustrates the use of an innovative, dynamic, and interactive approach to the rehabilitation of an athletic hamstring injury. A Trigenics® treatment protocol for a Grade II hamstring strain has been described with emphasis on the immediate and long term efficacy of this treatment modality.
Dr. David Gryfe graduated Magna Cum Laude (Clinic Honors) from CMCC in 1992. He then certified as Doctor of Acupuncture from the Open International University (Sri Lanka). Since 1993 he has been the director of a multidisciplinary health centre in Etobicoke integrating Chiropractic, Naturopathic, Registered Massage Therapy, Homeopathy and Rehabilitation based on T'ai Chi principles within a Medical facility. In addition Dr. Gryfe is associated with the Ruth Pettle Wellness Centre, Toronto Pain and Headache Clinic and Chiropractic consultant to the Woodbine Race Track. He completed his Fellowship with the College of Chiropractic Sports Sciences(Canada) in 1999. He is the author of "Always Beginning - a beginner's guide to T'ai Chi". Dr. Gryfe completed his Trigenics® program in fall 2002.
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