hamstring injuries – differential diagnosis and treatment
TRANSCRIPT
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Hamstring injuries –
differential diagnosis
and treatment options
Sakari Orava professor MD PhD
Turku, Finland
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Hamstring strains
� Most common muscle injury in soccerplayers (both males and females)
(Hägglund,Walden and Ekstrand, Scand J Med Sci Sports 19, 819-829, 2009)
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Hamstring muscles
� over two big joints
� pelvic stabilizers
� hip extensors
� anatomical variations
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Causes of hamstring area pain � lumbar disc prolapse or protrusion� disc degeneration – internal tear� spinal stenosis – nerve root canal stenosis� spondylolysis, -olisthesis� vertebral apophyseal ring fracture� vertebral anomalies� other radicular and pseudoradicular pains� neurological diseases� neuritis of sciatic nerve� neurinoma of sciatic nerve� ”tight hamstrings” - anomaly
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Hamstring / gluteal pains and injuries in athletes� piriformis syndrome� posttraumatic piriformis sdr – contusion of sciatic
nerve� hamstring syndrome� avulsion fracture of ischium� apophysitis of ischium� total and partial proximal muscle / tendon tears� mid-muscle (partial tears)� distal hamstring tears and avulsions� posterior compartment syndrome of thigh� posterior hip rotator injuries
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Piriformis syndrome
� first reported by Yeoman (1928)
� first liberation of sciatic nerve at glutealarea by Freiberg & Winke (1934)
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Piriformis syndrome- symptoms� pain at upper gluteal
area� radiation to posterior
thigh and down the leg� postexercise and night
pain� leg held in semiflexion
and in outward rotationin bed
� sitting usually OK, long time difficult
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Piriformis syndromeClinical findings Examinations� gluteal palpation pain over
the muscle/nerve� resisted abduction –
external rotation (Pace´ssign) usually +
� forced internal rotation of extended thigh (Freiberg´ssign)may be +
� piriformis streching +� neurological status –� local anesthetic injection
test +
� Clinical (most important)
� radiographs -
� ultrasound echo (?) - +
� MRI+ -
� ENMG+ -
� there is no spesific testor examination to diagnose piriformis sdr
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Piriformis syndrome –clinical entities
1.piriformis syndrome caused by contraction of
piriform muscle (from overuse)
2.piriformis sdr from muscle / nerve anomaly
3.posttraumatic piriformis syndrome (directtrauma - contusion of sciatic nerve)
4.radicular syndromes from lumbar spine causing
piriformis tightness
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Piriformis syndrome
� in 6.2 % part of sciatic nerve goesthrough piriformismuscle (Pecina, 1979)
� muscle may behypertrophic or itstendon anteriorlythick
� vascular anomaliesaround the nerve
� usually no abnormality seen in surgery
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Conservative treatment of piriformis syndrome� rest from physical exercise causing
symptoms� piriformis stetching� hip mobility exercises� pelvis (core) stability exercises� relaxation, masage physiotherapy, manual
treatment� corticosteroid injections
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Surgery for piriformis syndrome
� division of piriformis muscle(proximally)
� liberation of sciaticnerve fromadhesions,muscularanomalies orcompresivevascular anomalies
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Diagnosis of hamstringsyndrome� Running, sitting and car
driving difficult
� local pain at hamstringorigin
� MRI +, US +-,ENMG -
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Pathophysiology of hamstring syndrome= tendinosis (+ sciatic nerve irritation)
� stress, small tears, thickening, tendinosis
� semimembranosustendon mostly affected(=”fibrous band”)
� biceps femorissometimes, too
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”Posttraumatic”hamstring syndrome
� after partial tear or
after recurrent
small tears scarring,
fibrosis and
tendinosis occurs
to semimembr.- bic.fem
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Surgical treatment of hamstringsyndrome (from overuse)
� division of semimembr.band, liberation of sciatic nerve, proximal fasciotomy
� Only tendon divided, muscle part left intact
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Surgery for posttraumatichamstring syndrome- division of fibrous tendinosis tendon
- excision of scar clump
- fixation of distal stump to other
tendons or with suture anchor to bone
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Diff. diagnosis of piriformis and hamsting syndrome
� m. quadratus femoris
tear on right side
� ischiogluteal bursitis
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Avulsion fractures of ischialtuberosity� usually in young
athletes (13-18 years)
1. apophyseal ”tug” lesion
2. apophyseal partialseparation
3. periosteal avulsion withlater ”pseudotumor”
4. bony avulsions
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Avulsion / apophysitis of ischialtuberosity
� avulsion / fracture line
oblique – difficult to
see in native
radiographs
� side views, CT, MRI +
� surgery if separation
more than 2 cm,
individual decisions
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Apophysitis of ischial tuberosity
� in young athletes
(11- 17 years)
� radiographs positive
late
� MRI+, isotope scan +
� may last long
� Treatment: rest from
activity, drilling
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Apophysitis of ischial bone
� symptoms 4 weeks after 4months
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Surgery for apophysitis of ischium
� Holmstrom et al , Amer J Sports Med 2003
� ”Transapophyseal drilling to effect”apophysiodesis” – 16 year old female gymnast
suffered from chronic apophysitis and was treatedsurgically 9 months after the onset of the symptoms with
good result
� we have done drilling procedures and screw fixations
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Hamstring muscle and tendontears – Mechanism of hamstring tears
� forceful flexion of hip joint
with knee extended –
hamstrings contracted
� recurrent injuries often
� partial of total tear
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Partial hamstring tendon tears
� partial tear
� recurrent tears
� scar
� tendinosis
� adhesions
� nerve irritation
� --- ”postraumatic
hamstring syndrome”
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Partial insertional hamstringtears
� painful scar
� muscle atrophy
� poor healing in active athletes
� different types
� myotendinous tears
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Treatment of partial proximalhamstring tears� rest, rehabilitation, physiotherapy
� if posttraumatic hamstring syndrome occurs, cortcosteroid injections
� if recurrent injuries,long rest periods,inability to train, MRI +, hamstring sdr symptoms ---surgical treatment
� surgery: liberation, fasciotomy, division of tightscar bands, refixation to other insertions or to bone with suture anchors
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Total hamstring muscle tears
� massive hematoma
� relaxed muscle mass
� weakness
� invalidity
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Total / subtotal tears of hamstring muscles
� avulsed tendons
inside hematoma
/seroma cavity
� massive hematoma
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Surgery for total proximalhamstring origin tear
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Hamstring tears
- rupture / lesion of sciatic nerve branchesto hamstrings leads to: denervated proximalmuscle, neuromaes, elongation of repairedmuscle…
- 1-,2-,3- tendon tearsproximally
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Total hamstring avulsions / tears
� surgical treatment at early phase best treatment
� fixation of avulsed tendons to ischial bone with
suture anchors
� in old / negleted cases: anchor fixation and
augmentation, ”bridge” with fascia lata or
semitendinosus tendon
� results usually good, if no denervation or
neuromaes
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Total ruptures of hamstringslate repair with augmentation
� suture anchors fascial augmentation
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Mid- and distal hamstring tears
1. seroma cavity fromintramuscular tear
2. superficial mid-muscletear
3. distal myotendinoustear of biceps femoris
4. Distal avulsion
of biceps tendon
SURGERY SOMETIMES
1
2
3
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Posterior femoral compartmentsyndrome
� one of endurance athletes´ pain syndromes
� may occur after hamstring muscle tearsand recurrent injuries
� is treated with fasciotomy
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Hamstring injuries – pain syndromes
� our experiences are based on
- 250 hamstring syndrome operation
- 200 total and partial hamstring tearoperations
- 100 other operations at gluteal –hamstring area
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Primary / posttraumatic complications of gluteal / hamstring operations
� lesion of sciatic nerve from direct trauma
� lesion(s) of sciatic nerve branches to hamstringmuscles
� neuromaes of healing nerves
� elongation of denervated proximal hamstrings
� contractures, recurrent spasms
� muscle atrophy, weakness
� adhesions
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Secondary / postoperative complicationsof gluteal / hamstring operations
� postoperative bleeding / hematoma
� lesions to posterior cutateous femoral nerve
� lesions to muscular branches of sciatic nerve
� lesions to perineal nerve branches
� postoperative neuromaes
� postoperative infection, fistulae
� scar problem (keloid, transversal fissuraes)
� rerupture
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Hamstring injury in athletes
� hamstring injuries common in athletes
� usually healing well
� delayed healing may occur
� uncommon pain syndromes develop
� difficult to make right diagnosis
� difficult to make decision for surgical treatment
� usually possible to treat surgically with goodresult
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Lempainen Lasse: PhD Thesis on ”hamstringinjuries”, University of Turku, 2010
Sakari Orava, Lasse Lempainen, Janne Sarimo, Jouni Heikkilä, Kimmo Mattila
MEHILÄINEN, Hospital, SportsClinic and Sports Trauma Research Unit
Turku, Finland