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Ν.G.Malliaropoulos
[email protected]
MD, Msc & Dipl in SEM, PhD, ECOSEP , FFSEM(UK)
Consutant Sports &Exercise Physician Barts and The London
Senior Lecturer QMUL CSEM
Fellow Faculty Sports and Exercise Medicine (UK)
Director of the Athletics National Sports Medicine Centre Thessaloniki, Greece
Muscle injuries
Muscle injuries are among the
1. most common
2. most misunderstood, and
3. inadequately treated conditions in sports medicine.
•
According to some studies, muscle injuries account for 10 - 30% of all injuries in sport.
•
Muscle injuries often occur during sport or training with over 90% caused
more often by indirect trauma (overloading) OR by direct trauma (impact).
September 14th
George Malliaropoulos
2015
Hamstring Injuries Definition
Acute Non Contact Posterior Thigh Muscle injuries, with all the athletes reporting an
incidence during training or competition ,either structural or functional, presented with the
Musculoskeletal triad, leading to a time loss more than a day .
•Fuller C et al.Consensus statement on injury definitions and data collection procedures in studies of football (soccer) injuries.Scand J Med Sci Sports. 2006;16:83-92.
•Malliaropoulos NG. Non contact Hamstring injuries in sports. Muscles Ligaments Tendons J. 2013 Jan 21;2(4):309-11
•Malliaropoulos N,et al Posterior thigh muscle injuries in elite track and field athletes.. Am J Sports Med. 2010 Sep;38(9):1813-9.
•Askling CM, Malliaropoulos N, et al.High-speed running type or stretching-type of hamstring injuries makes a difference to treatment and prognosis. Br J Sports Med.
2012 Feb;46(2):86-7.
•Mueller-Wohlfahrt HW et al, Terminology and classification of muscle injuries in sport: the Munich consensus statement.Br J Sports Med. 2013 Apr;47(6):342-50.
•J Ekstrand, et al, Injury incidence and injury patterns in professional football: the UEFA injury study. Br J Sports Med 2011;45:553–558
Literature has emphasised HAM high clinical relevance in professional athletes.
Lower Limb Epidimiological Data Track&Field 1990-2011
Overuse injuries
Hamstring Injuries
Ankle Ligament Injuries
Knee Injuries
Quatro
Muscle
PTM strains
were the most common injury
Injuries
occurrence (16%), according with surveillance
study of the 2007 International Association of
Athletic Federations (IAAF) (2008)
Epidemiologically muscle injuries have been
increasing over the last 12 years despite assessing risk
factors and applying prevention protocols
HAMSTRING IS IT A CLINICAL PROBLEM ???
Classifying & Grading the severity of the NCHI does it matters?
Mechanism
Hamstring tears have personalities!
There are at least
TWO distinctly different types of acute NON Conatct hamstring pathology
The most common injury type occurs during high-speed running
and the other occurs during movements leading to extensive lengthening
of the hamstrings, such as; high kicking, sliding tackle and sagittal split.
High-speed running type is mainly located to the long head of biceps femoris
and typically involves the proximal muscle-tendon junction.
Stretching-type is located close to the ischial tuberosity and typically involves
tendon tissue of the semimembranosus.
A general rule of thumb is, ‘the closer to the ischial tuberosity, the longer the
rehabilitation period’.
High-speed running type or stretching-type of hamstring injuries makes a difference to treatment and prognosis.
Carl M Askling, Nikolaos Malliaropoulos, Jon Karlsson Br J Sports Med February 2012 Vol 46 No 2
By Imaging 2a
grade 0
a normal US
a normal US
grade 1
subtle US findings
ill-defined hyperechoic or hypoechoic intramuscular
areas or a swollen aponeurosis
grade 2
partial muscle tears
Haematoma formation
grade 3
complete muscle tears
Haematoma formation
•Peetrons P. Ultrasound of muscles. Eur. Radiol. 2002;12(1):35-43.
Longitudinal study comparing sonographic and MRI assessment of acute and healing hamstring injuries.
Connell DA, Schneider-Kolsky ME, Hoving JL, et al.
AJR Am J Roentgenol. 2004;183:975-984.
Value of Sonography Combined With Clinical Assessment to Evaluate Muscle Injury Severity in Athletes
Yannick Guillodo, MD; Ronan Bouttier, MD; Alain Saraux, MD, PhD Department of Rheumatology, Cavale Blanche
Teaching Hospital, Brest Cedex, France
Journal of Athletic Training 2011:46(5):500–504
Longitudinal study comparing sonographic and MRI assessment of acute and healing hamstring injuries.
Connell DA, Schneider-Kolsky ME, Hoving JL, et al.
Am J Roentgenol. 2004;183:975-984.
Classifying & Grading the severity of the NCHI does it
matters?
By Imaging 2b
The first MR study that described findings with poor prognosis of muscle
injury evaluated 14 patients and found that muscle rupture and
retraction, haemorrhage, ganglion-like fluid collections, and
greater than 50% cross-sectional involvement were associated with
convalescent periods of more than 6 weeks
Follow up during rehabilitation time ????
Location (Anatomical &Imaging )
describes an imaging (magnetic resonance or ultrasound) , which considers the
anatomical site, pattern and severity of the lesion in the acute stage
Acute muscle strain injuries: a proposed new classification system
Otto Chan , Angelo Del Buono , Thomas M. Best , Nicola Maffulli
Knee Surg Sports Traumatol Arthrosc 2012
MRI negative injuries
2014
Location (Anatomical &Imaging) focused
5 Grades in Total
 Classification based on extent (grades 0–4) and site (a, b or c) of injury
 Site of injury is determined as myofascial (a), muscular/musculotendinous (b) or
intratendinous (c).
 Extent of injury is determined by MRI features of the muscle injury.
M(Mechanism)L(Location) G(Grade)R (Re-injury)
2015
Does MRI helps ??
Askling has argued MRI diagnosis is helpful for distinguishing the two types of hamstring tears.
Jan Ekstrand et all ,2012 of 23 European professional team to include the largest study characterising
the severity of hamstring strain using MRI .
Remarkably, 70% of hamstring injuries seen in professional football
showed no signs of fibre disruption on MRI.!!!!!
Still, these injuries which occurred without imaging alterations caused the majority of days missed due
to injury. !!!!!!
Hamstring muscle injuries in professional football: the correlation of MRI findings with return to play.
Jan Ekstrand, Jeremiah C Healy, Markus Waldén, Justin C Lee Bryan English, Martin Hägglund. Br J Sports Med 2012;46:112–117.
CLINICAL 3A
 Time to walk pain-free > 24 h after a hamstring injury.
 previous hamstring injury
are predictors of time to return to competition and recurrence (4 weeks to RTP for the time to walk )
Clinical predictors of time to return competition and of recurrence following hamstring strain in elite
Australian footballers Price Warren, et al. Br J Sports Med 2010 44: 415-419
 According to the UEFA consensus discussions, injury severity must be categorized
as minimal (1-3 days absence), mild (4-7 days), moderate (8-28 days) and severe (> 28 days.)
‘it is therefore crucial to establish valid criteria to
recognise severity and
avoid premature return to full activity and
the risk of reinjury’.
POSTERIOR THIGH MUSCLE INJURIES IN ELITE TRACK AND FIELDATHLETES: A NOVEL CLINICAL CLASSIFICATION .
N Malliaropoulos , Nicola Maffulli ,et all . ΑJSM 2010
Classifying and Grading NCHI does it matters?-
Clinical 3B
POSTERIOR THIGH MUSCLE INJURIES IN ELITE TRACK AND FIELDATHLETES: A NOVEL CLINICAL
CLASSIFICATION .
N Malliaropoulos ,et all Am J Sports Med. 2010 Sep;38(9):1813-9
Classification based on:
1. Location(HAM) –Mechanism(Non Contact)
2. Clinical examination & re evaluation 48 hours post injury
3. Active range of motion (goniometry)
4. Ultrasonographically findings
5. Recorded time to full rehabilitation .
Hamstring injuries:
Malliaropoulos Thesis ,QMUL,MSc 1999.
Musculoskeletal Injury Triad
Clinical evaluation at 48 hours
All athletes were re-evaluated 48 hours after the initial injury, this included the following:
•Palpation of the posterior aspect of the thigh with the athlete prone to elicit tenderness if present
•Provocation of pain on isometric contraction of the posterior thigh muscles
•Provocation of pain on passive hip flexion with the athlete supine
1.Tenderness to palpation
2.Pain with resisted movement (Knee flexion, extension of the hip)
3.Pain with passive stretching flexion of the hip with the knee extended.
A-ROM both sides
POSTERIOR THIGH MUSCLE INJURIES IN ELITE TRACK AND FIELDATHLETES: A NOVEL CLINICAL CLASSIFICATION
N Malliaropoulos MD,Μsc-SEM, PhD. E.Papacostas MD,Orth. O. Kiritsi MD, A. PapaladaPT , N. Gougoulias MD,Orth,PhD, Nicola Maffulli MD, PhD, FRCS(Orth)
American Journal of Sports Medicine 2010
Clinical
Grade
AROM deficit
1ST
<10ο
2ND
degrees
FRT
Percentage (%)
Iamging
Treatment
6.9 (2.0)
45.4
10ο – 19ο degrees
11.7 (2.4)
35.2
U/S
Laser-PRP -Rehab
3D
20ο - 29ο degrees
25.4 (6.2)
15.8
MRI
Non Weight Bearing
Laser - PRP
4TH
>30ο
55.0 (13.5)
3.6
MRI
Operation??
degrees
Rehab
1st degree injuries are Functional injuries ????
Total ham ruptures are not common in Elite athletes


PROPER TREATMENT
Clinical value


PROPER REHABILITATION PROGRAM
Clinical value


ESTIMATION OF RETURN – TO – SPORTS TIME
Clinical Prognostic value


REDUCTION OF RECCURENCE
Clinical Prognostic value
Clinical relevance: ‘bye, bye MRI’?
In clinical practice, the diagnostic work up generally consists of history, physical examination
and, possibly, additional imaging.
Recent data clearly show that MRI did not provide additional prognostic information
Moen MH, et al Predicting return to play after hamstring injuries. Br J Sports Med 2014;48:1358–63.
Statistics on the table
There are many different factors determining RTP in hamstring injuries, and anatomical severity, as measured
by the MRI, is only one of the factors.
But the current available data show that MRI does not substantially contribute to the answer of the athletes’
most important and simple question after they are injured: ‘When can I return to play?’
Functional Assessment Scale for Acute Hamstring Injuries
a condition-specific patient-reported
 outcome measure
to measure symptoms and their effect on function and sports ability
History
Clinical
examination
48h POLICE
D.D
Follow up
Re evaluation
AROM
IMAGING
DEGREE OF SEVERITY
Early Clinical Assessment
FASH
Treatment
REHABILITATION
RTP
FASH
Thank you for your
attention!!!