EVERY SESSION IS AN ASSESSMENT SESSION
MAIN COMPLAINTS:
A 22-year-old male sprinter came with complaints of left hamstring and calf pain while running.
History:
He is a sprinter who clocked 10.79 seconds in the 100 meters, which is his PR. He was part of the SAI camp in Trivandrum and participated in the National Meet in 2022.
He feels a pulling kind of pain in his hamstring after sprinting over 200 meters and has started to experience tightness in both the hamstring and calf regions.
Past History:
He has previously strained his right hamstring 6 times, which he mentioned as a hamstring tear. He also mentioned experiencing recurrent pain in the left hip (sacral)and belt region 2 years ago. Bending forward was difficult as he had a sharp pain. He visited a few physios for this and they diagnosed it as SI joint dysfunction and one physio said that it was disc bulge. After that, he developed bilateral knee pain and a doctor diagnosed it as Osgood Schlatter’s. I feel so much confusion was created.
Personal History:
Good, active lifestyle, as he had regular training sessions, training 5 days/ week. The training plan, which he mentioned, is included below.
Monday | Tuesday | Wednesday | Thursday | Friday | Saturday |
Sprint repetitions 100*2 120*2 150*2 at submaximal speed | Weighted resistance training Evening: Plyometrics
| Core strengthening
| Mobility Evening: Own body strength/body weight training | Plyometrics Evening: Mobility
| Some endurance running around 15-20 mins
|
SLEEP: He sleeps well for about 8 hours every day.
STRESS: He feels stressed that he is unable to sprint to maximum speed
PREVIOUS TREATMENT DATA: He consulted a few doctors and physios, and did manual therapy in SAI along with some rehab exercises for back pain. Then he trained for 6 months without any injury. After that, within 4-5 months, he had a hamstring tear on the right side for around 6 times. (it could have possibly been a hamstring strain).
GOAL: He wants to return to sprint in 100m.
Pain Analysis:
INTENSITY | 6/10 while sprinting |
AGGRAVATING FACTOR | Sprinting / strides |
RELIEVING FACTOR | Rest |
LOCATION | Left side medial and lateral hamstrings |
DURATION | 2-3 months |
TYPE OF PAIN | Nociceptive pain |
CHARACTER | Intermittent -mechanical |
IRRITABILITY | High – when he sprints, symptoms immediately spike up |
SENSITIVITY | Moderate. It takes about 40-45 mins to subside after sprinting |
LIFESTYLE IMPACT | Affected as he is not able to sprint to his maximum potential |
FEAR OF MOVEMENT ANALYSIS | He is a bit worried about the ability to sprint at max speed. |
Clues from the history and pain analysis:
- Improper rehab and conditioning after the previous injury,
- Poor load management
- No proper return to sport criteria had been utilized in his rehab and training phase.
- He did not do proper rehabilitation after the hip and low back region pain, instead he continued with his sprint training.
- Since he had a right hamstring injury 6 times previously, it might be a possible cause for the current left hamstring strain. This is my assumption for now.
Physical Examination
ROM ANALYSIS:
- Knee flexion and extension- full ROM
- Right side hip External Rotation is reduced compared to the left. Previously, a right-side injury is evident, so it might be due to overuse, leading to mobility restriction
MOBILITY SCREENING:
FORWARD BENDING: Good
OVERHEAD SQUAT: Good with minimal shift to right side but not significant
Stability Screening: Strength Test
STRENGTH TEST: | RIGHT | LEFT |
Single-leg pistol squat | 14 (RPE 10) | 12 (RPE 10) |
Single hamstring bridge | 12 -no pain | 15 painful after 5th rep 3/10 |
CRANE SCALE TESTING: Max isometric strength testing | RIGHT IN KGS | LEFT IN KGS | Limb symmetry index LSI |
QUADRICEPS: Best of 3 is taken | 42.3 | 39.7 |
|
41.8 | 35.7 |
| |
49 | 43.8 | 89.3 | |
HAMSTRINGS: Best of 3 is taken | 26.2 | 29.4 pain (2/10) |
|
25.9 | 28.8 |
| |
23.4 | 29.4 | 112 |
Isometric strength test | Right | Left |
Side plank holds | 84secs | 58 secs |
Side plank leg lift hold | 66 secs | 49 secs |
Trunk lateral flexor endurance test:
Right | Left |
57 secs | 40 secs |
NOTE: (all testing was not done on the same day)
Hamstring quadriceps muscle imbalance is evident, which is a main risk factor for hamstring strain.
Single leg Glute bridge isometric holds were also done, but we did not document it, because while performing, in the left side he felt the hamstring and lower back from the start of the hold. Also, when we tried the repetition movement, it still felt either in the low back or in the hamstring, whereas on the right side he was able to perceive the gluteus muscle working well.
PALPATION: Mild pain in medial hamstrings on left side.
SPECIAL TEST:
- SLR- negative
- CROSS SLR- negative
- The abductor adductor break test was weak and pain-free on the left side
- Thomas’s test found that the left rectus femoris was tight compared to the right
- He complained of pain during hamstring bridging and hamstring crane scale testing, but went on with the test as it was tolerable and below 3/10 pain
Investigation
X-Ray: Nil
Blood Test: Nil
MRI scan: NIL
Differential Diagnosis:
Adductor strain: It can be ruled out as there was no pain or tenderness in the adductor region and adduction-based movements were not painful.
Lumbosacral referred pain: It can be ruled out as there is no hip or lower back pain at present and no neural involvement.
Overloaded on the left side due to previous 6 times strain: It can also be ruled out. We initially felt that, due to right side weakness, the left is overloaded, but testing gave a different outlook.
As we went on with the second session, we got information that he was unable to feel the gluteus muscles during hip thrust and single-leg bridging. Also, he felt either his hamstrings or lower back, then we checked the side plank on both sides and the results were evident.
Then he told me, while sprinting, he usually feels like rotating to one side with the right opening up a bit more.
Diagnosis:
- Patient’s perception about the pain was good.
- Psycho-social factors – Not affected.
- The Left hamstring strain is due to gluteus maximus insufficiency and poor trunk stability on the left side, which is the highly suspected reason for the previous 6-time strain on the right side.
- All this started because of the lower back and hip pain, which came after lifting heavy weight, and he did not address the root cause during that injury.
- Recurrent hamstring strain related overuse pain, the patient is not willing financially to take ultrasound or MRI imaging.
Treatment Planning:
Planned a Weekly one session for 8 weeks
First week:
- We did muscle strength testing using a crane scale and added some mobility exercises
- And educated him about the load management during this phase
Second week:
- During hip trust exercise, I came to know about hip extensor insufficiency, interacted with him, and came to know about a clear history of low back pain, which was more on the sacrum.
- How it started – he had competitively done 20 sets of plank with his friends, and the next day, low back pain was severe on the left side and he was unable to bend or move.
- As I collected all this information, I did some more tests to confirm my hypothesis.
Third week:
- I gave unilateral trunk strengthening exercises, focusing more on the left side along with hip stability exercises. Managed his running load and asked him to implement it.
Fourth week:
- He was feeling better during sprints at 80% of his effort, worked on eccentric strengthening of hamstrings and hip flexors.
- He was able to feel the left glute while doing hip extension movements.
- Educated him very clearly that slowly we can transfer him to training, and graded exposure to sprinting.
Note:
Initially I felt it’s due to overuse of the right leg -left hamstring injury has occurred, but it took 2-3 sessions to get clarity that due to improper rehabilitation done to the low back pain. Every single movement is an assessment, every single session can be an assessment, and we can get to know more information about the individual, which might lead to a better prognosis.