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Musculoskeletal clinical topic of the month – A Hamstring Injury Christmas Special

Hamstring Tear vs Avulsion 

Hamstring tendon and muscle injuries are common in athletes and recreational sports such as football, rugby and athletics. Most can be appropriately graded with MRI and then rehabilitated by evidence based protocols and a comprehensive return to run/sport programme. 

Hamstring avulsions on the other hand can cause significant disability.They commonly occur in adolescent athletes during sporting activities involving sudden, extreme, unbalanced and eccentric contracture of powerful muscles. They can however also occur in skeletally mature patients. Mechanism usually involves forceful flexion of the hip and simultaneous extension of the knee e.g. sprinting and hurdling. Patients often present with a history of acute pain at the buttock crease, a severely antalgic gait, loss of hip function and significantly reduced hamstring strength.

This newsletter describes an unusual case of complete hamstring tear, occurring just adjacent to the hamstring insertion, so shares characteristics of both hamstring tear and avulsion.

Clinical History

Clinical history;

  • 34-year-old man presented to LBSM with an acute right hamstring injury during Christmas Rugby
  • Mechanism – Leant over to retrieve ball with opposition player landing on his back, forcing a deep hip flexed position
  • Felt tearing sensation in buttock immediately fell to ground
  • Unable to stand up, had to be carried of pitch
  • Able to partial weight bear in the following few days and attended clinic 3 days post injury 

Past Medical history;

  • BMI 28
  • No previous hamstring injuries
  • Otherwise fit and well

Exercise history;

  • Plays Rugby once a week
  • Sporadic gym goer

Social history;

  • Works in accounting
  • Non-smoker
  • Good diet

Clinical examination (assessed day 3 post-injury);

  • Antalgic pattern on load bearing through right leg
  • Extension bruising all throughout posterior thigh, from glut to knee
  • Very weak power on prone knee bend
  • Mild Popeye deformity on hamstring activation

Next steps;

  • Significant Hamstring tear/ Hamstring avulsion suspected so MRI pelvis and thigh organised

Diagnostic Imaging

Full thickness rupture of the right semi-tendinosus muscle and semi-membranosus component of the right proximal common hamstring tendon. Common tendon still attached to Ischial Tuberosity so therefore not true Hamstring Avulsion. Distal retraction of the muscle by 11.4 cm. The appearance is consistent with a BAMIC grade 4c injury unusual pattern (with most injuries occurring at the MTJ).

hamstring injury 1 Musculoskeletal clinical topic of the month - A Hamstring Injury Christmas Special

Management

Rehabilitation

  • First 1 week
    • Game ready and elevation
    • Hamstring, quads and gluteal activation exercises e.g isometric prone knee bend
    • Double Leg stance
    • PWB with crutches
  • 2-4 weeks
    • Single Leg stance
    • Concentric activation e.g. resisted prone knee bends
    • Eccentric activation e.g. Double leg RDLs
    • Restoration of normal gait patterns
  • 4-8 weeks 
    • Weighted eccentric and concentric SL loading
    • Commencement of Askling’s Hamstring protocol to regain length
  • 8-12 weeks
    • Gentle return to light jogging
    • Walk/run programme
    • Ongoing strength training
  • 12+ weeks
    • Graduated return to sport
    • Back to rugby at 14 weeks

Medical

  • Haematoma drainage performed at 2 weeks
  • Hamstring repair considered at 3 weeks post injury
  • Due to initial positive response to rehabilitation, decided against surgical intervention

Patient Self monitoring tools

  • LBSM pain and symptom diary
  • LBSM load monitoring diary

Key Summary – Hamstring injuries

  • Hamstring avulsion must be considered in high hamstring injuries that occur from a high force mechanism, or external contributing force
  • This is particularly true in adolescent athletes
  • If diagnosis is delayed sciatica may develop as a result of irritation of the sciatic nerve, either through exuberant callus formation or when the avulsed fragment directly impinges
  • Treatment of hamstring avulsions may involve non-operative or operative management with the majority of avulsions treated conservatively
  • Indications for operative intervention may include significant displacement (greater than 1–3cm), fracture non-union or an inability to tolerate prolonged immobilisation
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    Orla Mulligan
    Administration and Social Media Manager
    Administration, LBSM

    Orla Mulligan is the administration and social media manager for LBSM. She has a strong background in sport having herself played netball at an elite standard for the U21s Northern Ireland team in the European Championships as well as the U21s competition for Saracen Mavericks.

    She understands youth sport pathways having herself played and training in the netball Kent regional pathway. She has a keen interest in most sports and a good understanding of how injury and illness can impact on the mind and body, as well as rehabilitation pathways.

    She looks forward to speaking and assisting LBSM patients and gives her best support to them during their treatment pathway.

    A day in the life of Orla involves communicating with patients via phone and email, managing and organising clinics, operations and media management.

    Outside of work, Orla is a gym enthusiast, enjoys tennis and still finds the time for an occasional game of netball.

    Maddie Tait
    BSc, MSc
    Associate, LBSM
    Musculoskeletal and Sports Podiatrist

    Maddie treats and manages complex foot and ankle injuries in London and Surrey.

    She is particularly interested in helping her patients improve their quality of life and achieve their personal goals, working closely with Foot and Ankle Consultants, Sports Medicine Doctors and Physiotherapists.

    Maddie has a sporting background herself having previously represented England in Hockey. She understands the demands of elite sport and the importance of physical and mental health. In her spare time, Maddie continues to enjoy an active lifestyle by running, cycling and attending a Pilates class.

    Having graduated from University of Brighton with a MSc (hons) in Podiatry, Maddie focused her career in Podiatric Sports Injuries and Biomechanics. Previously she completed a BSc (hons) in Sport Science at Loughborough University.

    A day in the life of Maddie involves consulting patients in clinic, performing gait and biomechanical assessments, measuring and fitting orthotics and braces. She also regularly teaches and presents at sports medicine and podiatry conferences.

    Outside of work, Maddie still finds time to play hockey and enjoys running and skiing.

    Mr Prakash Saha
    MBBS, PhD, FRCS
    Consultant Partner, LBSM
    Consultant in Vascular Surgery

    Mr Prakash Saha is a Consultant Vascular Surgeon at LBSM. He takes pride in providing the best possible results for his patients by using the most appropriate non-surgical and surgical methods based on clinical evidence, patient results and satisfaction.

    He treats fit and active people suffering with a range of cardiovascular issues, from painful leg swelling associated with exercise to venous insufficiency, post-thrombotic syndrome and leg ulcers. He also treats people with arterial system problems including poor circulation, compression syndromes and aneurysms. He carries out both endovascular and open aortic repair and has some of the best outcomes in the country.

    Mr Saha studied medicine at the United Medical & Dental Schools at Guy’s and St. Thomas’ Hospitals before completing his higher surgical training in London and the South East. During this time, he was awarded the prestigious NIHR Clinical Lectureship in Vascular Surgery at St. Thomas’ Hospital, giving him comprehensive training in open and endovascular techniques for treating arterial and venous disease. Prakash completed his aortic surgery training at the St. George’s Vascular Institute before carrying out a specialist fellowship at the Royal Prince Alfred Hospital, Sydney.

    Mr Saha regularly lectures and runs workshops across the globe on the latest surgical techniques to treat vascular disease. He has also been awarded a number of research grants from the Royal College of Surgeons, the Circulation Foundation, the Wellcome Trust, the Academy of Medical Sciences, and the British Heart Foundation, which has led to over 80 publications and the development of innovative technologies to help treat patients. For this work, Prakash has received a number of prizes, including the Venous Forum prize from the Vascular Society of Great Britain and Ireland, an International Young Investigator Award, and an Early Career Investigator Award from the American Heart Association.

    A day in the life of Mr Saha involves seeing patients in clinic, operating in surgical theatre or lecturing at his university. He also regularly teaches and presents at vascular and sports medicine conferences.

    Mr Saha is an avid cyclist and tennis player (although yet to get a set of Dr Seth!). Outside of work, he spends time with his family who consists of 3 children and enjoys travelling.

    Dr Gajan Rajeswaran
    MBBS, FRCR
    Consultant Partner, LBSM
    Consultant in Sports and Musculoskeletal Radiology

    Dr Gajan Rajeswaran is a Consultant Musculoskeletal Radiologist at LBSM, with an extensive background of working in elite sport. He is one of the most recognised radiologists in the sports medicine field. He provides top level imaging and medical diagnostic services for patients and athletes.

    Dr Gajan Rajeswaran completed his undergraduate medical training at Imperial College London and his radiology training at Chelsea & Westminster Hospital. He has obtained two post-CCT fellowships in musculoskeletal imaging. He was appointed as a consultant at Chelsea & Westminster Hospital in 2011.

    He has a passion for all sports having worked as a radiologist at the Glasgow Commonwealth Games and London World Athletic Championships and continues to support The Championships, Wimbledon. He also continues to work with a number of Premier League and Championship Football Clubs, Premier League Rugby Clubs, England Sevens Rugby, British Athletics and the Lawn Tennis Association.

    A day in the life of Dr Rajeswaran involves giving his expert opinion on investigations such as MRI and CT scans, x-rays and ultrasound. He also performs injection lists under ultrasound, CT and X-ray including spinal injections. He also regularly teaches and presents at sports medicine conferences.

    Dr Gajan Rajeswaran is an avid football fan and life-long fan of Tottenham Hotspur (for which he offers no apologies!). Outside of work, he spends time with his family and has a keen passion for photography.

    Dr Ajai Seth
    MBBS, BSc, MSc, MRCS, MRCGP, FFSEM
    Medical Director, LBSM
    Consultant in Sport and Exercise Medicine

    Dr Ajai Seth is a Sport and Exercise Medicine Physician. He has dedicated his career to helping people with sport and exercise related injury and illness. He consults and treats everyone from the elite athlete to the weekend warrior.

    Dr Ajai Seth is part of the British Tennis Sports Physician team at the LTA and has also provided cover to elite athletes at Wimbledon Tennis, European Tour Golf, Premier League Football, British Athletics, and the Men’s England Football academies as part of the FA.

    He also prides himself for working in disability sport and is currently the Chief Medical Officer for Team GB Wheelchair Tennis which has taken him to the Olympics and Paralympics.

    Dr Ajai Seth is dedicated to education, training and research and is a Senior Lecturer in Sports Medicine at King’s College London where he lectures in all aspects of Sports Medicine and Science.

    He also has a passion for travel and Expedition Medicine, which has seen him accompany medical, scientific and charity expeditions all around the world. He also has vast experience in treating musculoskeletal injuries from children and adolescents to veteran exercisers, both male and female.

    Dr Seth also has positions in leading Sport Medicine organisations, including the non-executive board for the UK’s largest Sports Medicine charity, BASEM and Past President for the Royal Society of Medicine. 

    A day in the working life of Dr Seth involves consulting his patients in clinic, performing diagnostics and ultrasound guided injections. He also regularly lectures and tutors students and presents at sports medicine conferences internationally. He also spends part of the working week at the National Tennis Centre, LTA, supporting British Tennis players.

    Outside of work, Dr Seth enjoys playing club tennis, triathlon, golf, running and skiing (but will give any sport a go!). He enjoys keeping fit and active and good quality family time with his wife and three children.