Ν.G.Malliaropoulos contact@sportsmed.grMD, Msc & Dipl in SEM, PhD, ECOSEP , FFSEM(UK)Consutant Sports &Exercise Physician Barts and The London Senior Lecturer QMUL CSEMFellow Faculty Sports and Exercise Medicine (UK)Director of the Athletics National Sports Medicine Centre Thessaloniki, Greece

Muscle injuries are among the 1. most common2. most misunderstood, and3. 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).

Muscle injuries

September 14th 2015

George Malliaropoulos

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

Lower Limb Epidimiological Data Track&Field 1990-2011

Overuse injuries Hamstring Injuries

Ankle Ligament Injuries

Knee Injuries

Quatro Muscle

Injuries PTM strains were the most common injury occurrence (16%), according with surveillance study of the 2007 International Association of Athletic Federations (IAAF) (2008)

Literature has emphasised HAM high clinical relevance in professional athletes.

HAMSTRING IS IT A CLINICAL PROBLEM ???

Epidemiologically muscle injuries have been increasing over the last 12 years despite assessing risk factors and applying prevention protocols

Classifying & Grading the severity of the NCHI does it matters?

There are at leastTWO 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

Mechanism Hamstring tears have personalities!

grade grade 00 a normal US a normal US a normal US a normal US

grade grade 1 1 subtle US findings subtle US findings ill-defined hyperechoic or hypoechoic ill-defined hyperechoic or hypoechoic intramuscular areas or a swollen aponeurosisintramuscular areas or a swollen aponeurosis

grade grade 22 partial muscle tearspartial muscle tears Haematoma formation Haematoma formation

grade 3 grade 3 complete muscle complete muscle tearstears

Haematoma formation Haematoma formation

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.

•Peetrons P. Ultrasound of muscles. Eur. Radiol. 2002;12(1):35-43.

By Imaging 2a

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 ????

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

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

MRI negative injuries

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.

2014

M(Mechanism)L(Location) G(Grade)R (Re-injury) 2015

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.

Does MRI helps ??

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

Classification based on: 1. Location(HAM) –Mechanism(Non Contact)

2. Clinical examination & re evaluation 48 hours post injury2. Clinical examination & re evaluation 48 hours post injury 3. Active range of motion (goniometry)3. Active range of motion (goniometry)

4. Ultrasonographically findings 4. Ultrasonographically findings

5. Recorded time to full rehabilitation .5. Recorded time to full rehabilitation .

Hamstring injuries:Malliaropoulos Thesis ,QMUL,MSc 1999.

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

Musculoskeletal Injury Triad

1.Tenderness to palpation2.Pain with resisted movement (Knee flexion, extension of the hip)3.Pain with passive stretching flexion of the hip with the knee extended.

Clinical evaluation at 48 hoursAll 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

A-ROM both sides

POSTERIOR THIGH MUSCLE INJURIES IN ELITE TRACK AND FIELDATHLETES: A NOVEL CLINICAL CLASSIFICATIONN 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

1st degree injuries are Functional injuries ????Total ham ruptures are not common in Elite athletes

Clinical Clinical GradeGrade

AROM AROM deficitdeficit FRTFRT Percentage (Percentage (%%)) Iamging Iamging Treatment Treatment

11STST <10<10οο degreesdegrees 66..99 (2. (2.00)) 45.445.4 Rehab Rehab

22NDND 1010οο – 1 – 199οο degreesdegrees 1111..77 (2. (2.44)) 35.235.2 U/SU/S Laser-PRP -Rehab Laser-PRP -Rehab

33DD 2020οο - 29- 29οο degreesdegrees 25.25.4 (6.2)4 (6.2) 15.815.8 MRI MRI Non Weight Bearing Non Weight Bearing Laser - PRP Laser - PRP

44THTH >30>30οο degreesdegrees 55.0 (13.5)55.0 (13.5) 3.63.6 MRI MRI Operation??Operation??

PROPER TREATMENTPROPER TREATMENT Clinical value

PROPER REHABILITATION PROGRAMPROPER REHABILITATION PROGRAM Clinical value

ESTIMATION OF RETURN – TO – SPORTS TIMEESTIMATION OF RETURN – TO – SPORTS TIME Clinical Prognostic value

REDUCTION OF RECCURENCEREDUCTION 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 informationMoen MH, et al Predicting return to play after hamstring injuries. Br J Sports Med 2014;48:1358–63.

Statistics on the tableThere 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 measureto measure symptoms and their effect on function and sports ability

HistoryHistory

Clinical Clinical examinationexamination

D.DD.D

Follow upFollow up

Re evaluationRe evaluation A R O M A R O M IMAGING IMAGING

DEGREE OF SEVERITYDEGREE OF SEVERITY

FASHFASH

TreatmentTreatmentREHABILITATIONREHABILITATIONRTPRTPFASHFASH

48h POLICE 48h POLICE

Early Clinical Assessment

Thank you for your

attention!!!