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MRI Accuracy in Predicting Recovery of Hamstring Injuries

This study investigates the role of MRI in predicting recovery and recurrence of hamstring muscle strains in professional footballers. The research aims to improve the understanding and management of these injuries to facilitate early and accurate prognosis. Findings from a five-year prospective study are discussed, including MRI diagnostics, rehabilitation methods, and return-to-play criteria. The study reveals insights into the prognosis and recurrence of hamstring strains, offering valuable information for sports medicine practitioners.

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MRI Accuracy in Predicting Recovery of Hamstring Injuries

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  1. HAMSTRING INJURY

  2. The accuracy of MRI in predicting recovery and recurrence of hamstring muscle strains • Dr N Gibbs • Dr T Cross • Mr M Cameron • Dr M Houang J Sci Med Sport. 2004 Jun

  3. Introduction • Literature review • Methods • Results and Discussion • Conclusions • Questions??

  4. Clinical Scenarioe.g.. Posterior thigh pain 7 days before World Cup FinalCan he play??

  5. 1. Introduction

  6. Objective • To describe the MRI findings of a series of acute hamstring muscle strains (i.e. “posterior thigh pain”) • Do these MRI findings help • Predict the PROGNOSIS • Predict The RECURRENCE RATE

  7. Setting • Sydney Swans Football Club • 1 of 16 clubs in the National competition

  8. Design Prospective study over 5 years (1999-2003): Both in-season and pre-season periods

  9. Patients 40professional footballers Consent from Club and individual players

  10. Australian Rules Football “Athletes at risk” • Repetitive sprinting efforts • Repetitive kicking • Repetitive jumping & landing • Game time approximately 100 minutes

  11. Australian Rules Football Ideal sport ( “outdoor laboratory”) to study muscle strain injury

  12. Australian Rules Football Hamstring strain is the most significant injury in ARF (Quadriceps strain in top 10)

  13. Motivation for research • To better understand/diagnose Hamstring muscle strains • To better manage/rehabilitate Hamstring muscle strains

  14. Motivation for research • To make an EARLY ACCURATE PROGNOSIS (i.e. we were unable to clinically differentiate benign from serious Hamstring strains)

  15. Motivation for research • To better understand which “hamstring” injuries recur

  16. 2. Literature Review

  17. Anatomy Hamstrings, an “at-risk muscle” • Acts eccentrically • Crosses two joints • High % fast twitch fibres

  18. Function Main Function during sprinting And kicking is to deceleration of knee extension and hip flexion

  19. AFL injury database • Cause 20% of all missed AFL games • Recurrence rate 34%

  20. Literature review Pomeranz (1993) • Retrospective study of Hamstring strains • n=14 • Prognosis associated with size (cross-sectional area%) of muscle strain injury on MRI scan

  21. 3. Methods

  22. Methods Inclusion criteria • History acute onset of posterior thigh pain/ache or tightness while training or playing • Examination : tenderness over the posterior thigh : other signs elicited but not the subject of this study

  23. Methods Exclusion criteria • History of trauma to posterior thigh (Contusion) • Delayed onset of posterior thigh pain (DOMS) • Recurrence of posterior thigh pain in ipsilateral thigh in same season

  24. Methods MRI within 24-72 hours • T1,T2 with fat suppression, STIR • Axial, coronal planes (both thighs imaged) (Axial T2with fat suppressionmost useful images)

  25. Methods Muscle strain injury= high signal on T2 weighted images

  26. Methods MRI diagnosis Location (MRI category) • Which Hamstring muscle (s) injured • Location of injury with respect to known musculotendinous junctions

  27. Methods MRI diagnosis Size • Cross sectional area % (CSA) • Length (cm)

  28. Methods • CSA% estimation (“dot” method)

  29. Estimation of Length

  30. Methods MRI diagnosis: miscellaneous features… • T2 hyper intensity • muscle fibre disruption • Perifascial fluid • Scarring/fibrosis

  31. Methods What if more than one muscle injured? (i.e. double injury etc.) • Primary muscle injured= greatest CSA% • Secondary muscle injury= smaller CSA%

  32. Methods (rehabilitation phase) • No universally accepted rehabilitation regimen exists for muscle strain injuries

  33. Methods (rehabilitation phase) Rehabilitation was standardised Phase 1 : Acute management • RICE/crutches first 48 hours • Intensive Physiotherapy • soft tissue therapy • flexibility • strengthening

  34. Methods (rehabilitation phase) Phase 2: Remodeling phase • Eligible to start running program when, • Full pain free ROM • Complete 3 x 10 repetitions of single leg hops pain free • 4 Stage running/kicking program (sport specific to ARF) was designed at beginning of study

  35. Methods (rehabilitation phase) 4 stage running/kicking program • Run alternate days • Physiotherapist/Sports Scientist supervision • Combined with intensive physiotherapy • 5 minute jog warm up/cool down • Stage 1 : jog 10 mins x 2 • Stage 2 : 80m intervals ( 40-60 %) 3x 5 repetitions • Stage 3: 80m intervals (90-100%) 3 x 5 repetitions (staged kicking program commenced) • Stage 4: 80m intervals (sport specific drills at 90-100%) 3 x 5 repetitions • Integrate into team training

  36. Methods (rehabilitation phase) 4 stage running/kicking programs • Some advanced rapidly • Others delayed by symptoms of high grade posterior thigh pain, weakness and dysfunction Decision to return to Full Training : Collaborative

  37. Rehabilitation interval (RI) RI= time from the injury to the return to full training (measured in days)

  38. 2. Results and Discussion

  39. Results of acute MRI images • 31 acute clinical HAMSTRING strains were imaged • Authors were not blinded to these MRI’s

  40. Recurrent hamstring injury • Of the 17 MRI positive cases (“hamstring muscle strains”) • N= 6 recurred within same season!! • 35% recurrence rate • Size of muscle strain injury (length &/or CSA%) did NOT predict risk of recurrence

  41. Recurrent hamstring injury • Of the 14 MRI negative cases • None recurred within same season!! • 0 % recurrence rate

  42. Statistical analysis Statistician analyzed data • t-tests independent samples (dependent vs. independent variables) • Two-way analysis of variance

  43. Results: Statistical analysis (days) RI MRI Positive MRI Negative

  44. MRI Positive • n=17 • Mean RI=20.2 days • significantly longer RI (p=0.001)

  45. Results: Statistical analysis (days) RI

  46. MRI & Prognosis • Length of intra-muscular signal correlates best with RI r=0.84, p<0.001 • CSA% & RI r=0.78 • Size really does matter

  47. MRI negative cases • n=14 • Mean RI= 6.6 days (benign injury)

  48. MRI negative cases Hypotheses • MRI done too early • Strain injury too small to resolve • Other causes of “Posterior thigh pain”

  49. Other causes of posterior thigh pain • Somatic Referred pain • Lumbosacral spine • Pelvis

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