Lesões dos isquiotibiais: artigo de atualização

Potential financial loss and risk factors for hamstring muscle injuries in elite male Brazilian soccer players: a season-long prospective cohort pilot study

Purpose

The aim of this pilot study was to analyze the potential financial loss and a range of potential risk factors for hamstring muscle injuries in elite Brazilian soccer.

Methods

Thirty-four male players (age: 25 ± 6 years; stature: 180 ± 8 cm; body mass: 78 ± 9 kg; minutes played in matches: 2243 ± 1423 min) from an elite professional soccer club were monitored during a 12-month season. Muscle injury was identified by magnetic resonance imaging and the severity was defined according to the number of days away: minimal (1-3 days), mild (4-7 days), moderate (8-28 days), severe (>28 days). Potential financial loss due to the team's under achievements was determined. Dorsiflexion range of motion, eccentric knee flexor strength and isokinetic tests were performed during the pre-season. Association between dependent variables and the occurrence of injury was evaluated.

Results

Nine hamstring muscle injuries with moderate severity were found in 8 athletes. Recovery time was 22 days off the field on average. Potential financial loss was $-43.2 million USD and earnings on merit money was 21%. Previous injury, increased flexor deficit 60° /sec and increased flexor fatigue index 300°/sec were all associated with a greater chance of hamstring muscle injury. Ankle dorsiflexion range of motion was significantly lower in the injured group (35.6 ± 3° vs. 39.1 ± 4.9°; p = 0.017, effect size = -0.74).

Conclusion

High financial burden was found in elite Brazilian soccer during one full season. Injured athletes had high hamstring fatigue index, knee flexor strength deficit, ankle range of motion restriction and previous hamstring muscle injury when compared to non-injured athletes. Therefore, preventive approaches in professional soccer players with previous hamstring injuries should be a priority.

Semitendinosus and biceps femoris long head activity during the single leg bridge test in healthy individuals

INTRODUCTION

The single leg bridge test (SLBT) has been suggested as a clinical test to examine function, screen injury risk, and monitor the effectiveness of rehabilitation programes targeting the hamstring. This study aimed to determine the inter-day reliability and repeatability of both SLBT performance, semitendinosus (ST), and biceps femoris long head (BFlh) surface electromyography (sEMG) responses and characterise the BFlh and ST electrical activity during the SLBT performed until exhaustion in healthy individuals.

METHODS

Twelve physically active young men without previous hamstring injury were tested for the number of repetitions attained, and sEMG signal median frequency and amplitude in both ST and BFlh of each lower limb, randomly in two sessions, with a seven-day interval between sessions.

RESULTS

High reliability [ICC = 0.85] was found for the number of SLBT repetitions attained. Reliability of sEMG outcomes showed better results for ST (ICC = 0.62-0.91) than for BFlh (ICC = 0.39-0.81), and a high to very-high repeatability was found for both ST (ICC = 0.91-0.84) and BFlh (ICC = 0.91-0.85). sEMG median frequency decreased and amplitude increased for both BFlh (p ≤ 0.001) and ST (p ≤ 0.039) at the end of SLBT, suggesting localised fatigue.

CONCLUSIONS

The SLBT performed by healthy individuals until exhaustion proved to be reliable and to induce fatigue in both BFlh and ST, where the sEMG median frequency and amplitude can be measured on different days with acceptable reliability and high repeatability, suggesting its potential future use in both practical and clinical settings.

Surgical treatment of distal hamstring tendon injuries yield a higher return-to-sports rate: A systematic review

PURPOSE

The purpose of this study is to compare the patient-reported outcomes and return to sports of the conservative and surgical treatment of distal hamstring tendon injuries.

METHODS

Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, two reviewers searched PubMed, Scopus and Virtual Health Library databases in January 2023. Clinical studies evaluating conservative or surgical management outcomes of distal hamstring tendon injuries were considered eligible for this systematic review if predefined criteria were fulfilled: (1) published in English or Spanish; (2) evaluated any of the following: patient-reported outcomes, return-to-sports rate (RTS-R) or return-to-sports time (RTS-T). Data were presented in tables using absolute values from individual studies and derived pooled percentages.

RESULTS

Eighteen studies were included for 67 patients and 68 distal hamstring tendon injuries. Initially, 39 patients (58.2%) underwent surgical treatment, whereas 28 (41.8%) were treated conservatively. Among conservative treatment patients, 15 failed and had to be operated on (53.6%), all with distal semitendinosus tendon injuries. Anchor fixation was the technique of choice in 20 lesions (36.4%), tenodesis in 16 (29.1%), tenectomy in 14 (25.5%) and sutures were preferred in five (9%). Thirteen out of 28 patients (46.4%) undergoing initial conservative treatment returned to sports at a mean of 3.6 months (range 1 week to 12 months), in contrast to surgical treatment, in which 36 out of 39 patients (92.3%) returned at a mean of 4.2 months (range 6 weeks to 12 months). Additionally, 14 of 15 patients (93.3%) converted to surgical treatment after failed conservative treatment returned to sports at a mean of 7.6 months after injury.

CONCLUSION

Initial surgical treatment of distal hamstring tendon injuries yields a high RTS-R (92.3%) at a mean of 4.2 months. Furthermore, 15 out of 28 patients (53.6%) initially treated conservatively had to be operated on, delaying the RTS-T (mean 7.6 months after injury) without affecting their RTS-R.

LEVEL OF EVIDENCE

IV.

Therapeutic Exercises and Modalities in Athletes With Acute Hamstring Injuries: A Systematic Review and Meta-analysis

CONTEXT

Hamstring strain is a common injury to the lower limbs. Early intervention in the acute phase aids with restoring hamstring function and prevents secondary related injury.

OBJECTIVE

To systematically review and summarize the effectiveness of exercise-based interventions combined with physical modalities currently used in athletes with acute hamstring injuries.

DATA SOURCES

Five databases (EMBASE, Medline, Cochrane Library, SPORTDiscus, and Web of Science) were searched from inception to July 2021.

STUDY SELECTION

A total of 4569 studies were screened. Nine randomized controlled trials (RCTs) on the effect of therapeutic exercise programs with and without physical agents in athletes with acute hamstring injuries were identified for meta-analysis.

STUDY DESIGN

Systematic review and meta-analysis.

LEVEL OF EVIDENCE

Level 1.

DATA EXTRACTION

The studies were screened, and the evidence was rated using the PEDro scale. Nine RCTs with PEDro scores ranging between 3 and 9 were included and extracted pain intensity, time to return to play (TTRTP), and reinjury rate in the study.

RESULTS

Loading exercises during extensive lengthening were shown to facilitate TTRTP at P < 0.0001 but did not prevent recurrence (P = 0.17), whereas strengthening with trunk stabilization and agility exercise did not reduce the duration of injury recurrence (P = 0.16), but significantly reduced the reinjury rate (P < 0.007) at a 12-month follow-up. The results of the stretching programs and solely physical modalities could not be pooled in the statistical analysis.

CONCLUSION

The meta-analysis indicated that a loading program helps athletes to return to sports on a timely basis. Although strengthening with trunk stabilization and agility exercise cannot significantly reduce recovery time, the program can prevent reinjury. The clinical effects of stretching programs and pure physical modality interventions could not be concluded in this study due to limited evidence.

PROSPERO REGISTRATION

CRD42020183035.

Chronic Ischial Avulsion Fracture Excision With Primary Proximal Hamstring Repair: A Technique

Ischial avulsion fractures classically occur in the pediatric population and are relatively uncommon. These injuries are treated conservatively; however, in cases where there is greater than 2 cm of displacement, surgical intervention is recommended. In some cases, displaced fractures are either misdiagnosed or proper treatment is neglected, and patients who transition into adulthood are left with chronic nonunions that can become a source of pain and disability. Here we present a surgical technique for a chronic ischial avulsion fracture nonunion that is excised, and the hamstring tendons are then primarily repaired to the ischium using suture anchors.

Hamstring Strain Injury in Athletes

Hamstring strain injury (HSI) may result in considerable impairment, activity limitation, and participation restriction, including time lost from competitive sports. This CPG includes sports-related overloading and overstretching injuries to myofascial or musculotendinous structures in any combination of the 3 hamstring muscles (the semitendinosus, semimembranosus, and biceps femoris). J Orthop Sports Phys Ther 2022;52(3):CPG1-CPG44. doi:10.2519/jospt.2022.0301.

Classifying Ischial Tuberosity Avulsion Fractures by Ossification Stage and Tendon Attachment

BACKGROUND

We propose a new classification system for ischial tuberosity fractures in adolescents that is based on the ossification pattern of the apophysis.

METHODS

We performed a retrospective review of patients who were diagnosed with ischial tuberosity avulsion fractures at a single institution from 2008 to 2018. Skeletal maturity and fracture location, size, and displacement were recorded based on initial injury radiographs. The fractures were classified by location as being lateral (type 1) or complete (type 2). Pelvic computed tomography (CT) review demonstrated 5 stages of ossification. We then reviewed pelvic CT and magnetic resonance imaging scans to assess the tendinous insertions at the ischial tuberosity apophysis. Reliability analysis was performed.

RESULTS

We identified 45 ischial tuberosity fractures. The mean patient age was 14.4 years (range, 10.3 to 18.0 years). Boys accounted for 82% of the cohort. Forty-seven percent of the fractures were classified as type 1, and 53% were classified as type 2. Type-1 fractures were associated with younger age (p = 0.001), lower Risser score (p = 0.002), lower modified Oxford score (p = 0.002), less displacement (p = 0.001), and smaller size (p < 0.001) when compared with type-2 fractures. Of the 45 patients, 18 had follow-up of >6 months, with 56% going on to nonunion. Nonunion was associated with greater displacement (p = 0.016) and size (p = 0.027). When comparing union rates by fracture type, 33% of type-1 fractures progressed to nonunion, while 78% percent of type-2 fractures progressed to nonunion; however, this difference was not significant (p = 0.153). A review of the advanced imaging indicated that type-1 fractures involved the semimembranosus and conjoined tendons, whereas type-2 fractures also involved the adductor magnus tendon.

CONCLUSIONS

We propose a new classification system based on the ossification pattern of the ischial tuberosity apophysis that reflects the skeletal maturity of the patient, the size and location of the fracture, and the amount of displacement, and likely predicts the probability of subsequent nonunion. The ischial tuberosity ossifies in a pattern similar to the iliac crest as described by Risser, and this pattern of ossification dictates the size of the ischial tuberosity avulsion fracture fragments and the involved tendons.

Hamstring strains in professional rugby players result in increased fascial stiffness without muscle quality changes as assessed using shear wave elastography

INTRODUCTION

Hamstring strain injury is common among sports injuries. A previous history of this injury is considered a strong predictor of recurrent hamstring strain injury. Fascial tissue reportedly becomes stiffer after hamstring strain injury. However, the association between fascial stiffness and previous hamstring strain injury has not been investigated in clinical studies. We aimed to determine whether a previous history of hamstring strain injury affects fascial tissue and muscle tissues using shear wave elastography.

METHOD

In eleven male professional rugby players, the stiffness as a shear modulus (kPa) of fascial tissue and muscle was measured on the specific injured area measured by magnetic resonance imaging (MRI) at resting position by using shear wave elastography. The side-to-side differences between the injured and the uninjured side were analyzed. The length and area of the muscle scar tissue were evaluated by MRI in relation to fascial stiffness.

RESULTS

The shear elastic modulus of fascia was stiffer in the injured vs. the uninjured side; however, no difference was observed in the muscle. No significant relationship was detected between the length and area of the muscle scar tissue (all P > 0.05).

DISCUSSION

Rugby players with a previous history of hamstring strain injury exhibited passive stiffness of fascial tissues in the injured leg, regardless of the length or area of the muscle scar tissue. However, the passive stiffness of muscles was same between the injured and the uninjured leg.

CONCLUSION

The results can be beneficial to consider future risk for hamstring strain injuries.

The value of MRI STIR signal intensity on return to play prognosis and reinjury risk estimation in athletes with acute hamstring injuries

OBJECTIVES

Previous studies have shown low to moderate evidence for a variety of magnetic resonance imaging (MRI) features as prognostic factors in athletes with hamstring injuries. Short-tau inversion recovery (STIR) signal intensity has not yet been investigated for assessing the prognosis of acute muscle injuries. Our aim was to explore the relationship between MRI STIR signal intensity and time to return to play (RTP) and to investigate the association between MRI STIR and reinjury risk in athletes with acute hamstring injuries.

STUDY DESIGN

Case-control study.

METHODS

We used MRI STIR to measure intramuscular signal intensity in patients with clinically diagnosed hamstring injuries at two time points: at injury and RTP. At injury, we calculated the association of MRI STIR signal intensity with the time to RTP and reinjury risk. At RTP, the association of MRI STIR signal intensity and reinjury risk and the change in MRI STIR signal intensity over time on reinjury risk was evaluated.

RESULTS

51 patients were included. We found increased MRI STIR signal intensity: (1) at time of injury not to be associated with time to RTP, (2) at time of injury to be associated with a slightly lower risk for reinjury: odds 0.986 (0.975-0.998, p=0.02) and (3) at RTP not to be associated with reinjury risk. (4) We found no association between the change in MRI STIR signal intensity over time and reinjury risk.

CONCLUSION

Increased MRI STIR signal intensity at injury has no value in time to RTP prognosis, but is associated with a reduced reinjury risk.

Acute Tennis Injuries in the Recreational Tennis Player

Background:

Epidemiological studies on tennis injuries are mainly conducted in either elite professional or junior players. Injury patterns might differ in the recreational tennis player.

Purpose:

To investigate acute injuries in the recreational tennis–playing population with an additional focus on acute injuries that require surgical treatment.

Study Design:

Case series; Level of evidence, 4.

Methods:

A retrospective data analysis was conducted among patients who sustained an acute tennis injury between January 2013 and December 2018 and who had treatment administered at a single university hospital. Demographic data, diagnosis, body region of the trauma, injury mechanism, and treatment methods were recorded. Data were evaluated using descriptive statistics.

Results:

A total of 449 patients sustained 467 injuries (148 female, 301 male; mean age, 43.6 years; range, 8.2-84.4 years). The injuries occurred throughout the year, with an increased prevalence in the summer months. Injuries occurred in the lower extremity in 59%, the upper extremity in 30%, and the head and trunk in 11%. The main reason for an injury was a twist of a specific joint (n = 194) or a fall (n = 102). Harmless contusion or strains were the most common injury (49%). Ankle sprains were the most common serious injury, occurring in 11% of patients. Fractures occurred in 54 cases (12%). Overall, 9% of patients were treated surgically (fractures, n = 13; meniscal tears, n = 8; Achilles tendon ruptures, n = 6), and surgery was advised to another 1% who did not receive surgery at the study hospital.

Conclusion:

Typical acute injuries in recreational tennis players differ from acute injuries in elite and junior players, with an increased fracture occurrence. The main causes of acute tennis injuries are falls and twists, with 10% of injuries needing surgical treatment, mainly for fractures, meniscal tears, and Achilles tendon ruptures.

Hamstring muscle injury in the athlete: state of the art

Hamstring injuries (HSI) are the source of significant impairment and disability for both professional and recreational athletes. The incidence and prevalence of HSIs has been well documented in the literature, as they are among the most common soft tissue injuries reported. The significant time loss due to injury and the inherent risk of reinjury pose a significant issue to the athlete, their career longevity and the success of their respective team. This review will deal predominantly with describing the prevalence and incidence of HSI in athletes, discuss risk factors and the mechanisms of injury for HSI, how to properly diagnose, image and prognosticate appropriate return to sport (RTS) for individuals who have sustained an HSI, prescribe treatment and prevention strategies and to discuss relevant options to decrease overall risk of primary and secondary recurrence of HSI.Current treatments of acute HSI necessitate a thorough understanding of the mechanism of injury, identifying muscle imbalances and/or weakness, inclusion of eccentric and concentric hamstring (HS) and hip extension (HE) exercises, evaluation of pathokinematic movement patterns and use non-surgical methods to promote healing and RTS. This methodology can be used prospectively to mitigate the overall risk of HSI. Injection therapies for HSI, including ultrasound-guided platelet-rich plasma and corticosteroids, may impart some short-term benefit, but the existing literature is largely inconclusive with respect to long-term functional outcomes. Future directions should prioritise injury prevention, early diagnosis and targeted interventions that combine both non-surgical and minimally invasive orthobiological approaches and identifying biomechanical risk factors prospectively to mitigate risk.

Study protocol for a double-blind, randomised placebo-controlled trial evaluating clinical effects of platelet-rich plasma injection for acute grade-2 hamstring tear among high performance athletes

INTRODUCTION

Hamstring injury among athletes often results in significant morbidity. Currently, there are controversies regarding the clinical use of platelet-rich plasma (PRP) for the treatment of acute hamstring injury.

METHODS AND ANALYSIS

This study is a single-centre double-blind randomised placebo-controlled trial. Sixty-eight patients will be randomised to receive under ultrasound guidance either a single injection of leucocyte-rich PRP (LR-PRP) or normal saline. All patients will undergo a standardised hamstring rehabilitation programme under the supervision of a sports physiotherapist. Outcome data will be collected before intervention (baseline), and thereafter on a weekly basis. The primary outcome measure is the duration to return-to-play. It is defined as the duration (in days) from the date on which the injury occurred until the patients were pain-free, able to perform the active knee extension test and have regained hamstring muscle strength. Secondary outcome measures include assessment of pain intensity and the effect of pain on to day-to-day functions using the self-reported Brief Pain Inventory-Short Form questionnaire. Both the primary and secondary outcomes were assessed at baseline and thereafter once a week until return to play. Also, hamstring injury recurrence within the first 6 months after recovery will be monitored via telephone. The results of this study will provide insights into the effect of LR-PRP in muscle and may help to identify the best PRP application protocol for muscle injuries.

ETHICS AND DISSEMINATION

Ethics approval were obtained from the Medical Research Ethics Committee of the University of Malaya Medical Centre. Results of this trial will be submitted for publication in a peer-reviewed journal.

TRIAL REGISTRATION NUMBER

ISRCTN76844299.

Lower Extremity Biomechanical Examination of Athletes

A comprehensive lower extremity examination is a critical examination component for any type of injury in an athlete but should also be part of a preseason or preventive care program. Identification and treatment of biomechanical abnormalities and association with evidence-based risk factors for lower extremity disorders can be incorporated to potentially reduce risk or prevent acute and chronic injuries.

Running Propensities of Athletes with Hamstring Injuries

The current study aims to compare the mechanical propensities between healthy runners and runners with hamstring injuries. Retrospective case-control video analysis was used. A total of 35 (12 male and 23 female) videos of runners with hamstring injuries were compared with videos of sex-, age-, mass-, and height-matched healthy control runners. The main outcome variables were trunk posture angles, overstride angles, and foot strike patterns. An independent t-test and chi-squared tests were employed to analyze the main outcome variables between the runners with hamstring injuries and the healthy control runners. The statistical significance of less than 0.05 (p < 0.05) was used. The runners with hamstring injuries had a 1.6° less forward-trunk posture angles compared with the healthy control runners (p = 0.043). Also, the runners with hamstring injuries demonstrated a 4.9° greater overstride angles compared with the healthy control runners (p = 0.001). Finally, the runners with hamstring injuries had a tendency of rearfoot strike, while the healthy control runners showed a forefoot strike pattern (p = 0.004). In conclusion, the runners with hamstring injuries demonstrated different running mechanical propensities compared with the healthy runners.

Anatomy of proximal attachment, course, and innervation of hamstring muscles: a pictorial essay

Hamstring injuries are very common in sports medicine. Knowing their anatomy, morphology, innervation, and function is important to provide a proper diagnosis, treatment as well as appropriate prevention strategies. In this pictorial essay, based on anatomical dissection, the detailed anatomy of muscle-tendon complex is reviewed, including their proximal attachment, muscle course, and innervation. To illustrate hamstrings' role in the rotational control of the tibia, the essay also includes the analysis of their biomechanical function.Level of evidence V (expert opinion based on laboratory study).