MUSCULOSKELETAL DIAGNOSIS

DIAGNOSIS AND MANAGEMENT OF POSTERIOR THIGH PAIN

By Lee Herrington, MCSP

Hamstring injuries are often cited as being the most com- mon muscle injury that sports people face. In addition, research has shown that injuries causing pain in the poste- rior thigh are responsible for the greatest amount of time away from sports participation and recurring hamstring injuries are rarely out of the news, having sidelined a num- ber of high profile sports personalities at key times in the national and international sporting calendar. So why is it that hamstring problems appear so difficult to treat and reoccurrence happens so frequently?

For treatment of hamstring pain to be successful, appropri- ate rehabilitation programmes need to be developed. This can only be achieved with accurate diagnosis of the underly- ing cause of the hamstring pain. This article investigates many of the potential causes of hamstring pain and describes the presentation of many common clinical condi- tions relating to hamstring injuries. Techniques and advice on the differential diagnosis of each injury and their own specific management approaches are also included. This leads into an accompanying feature focusing specifically on the rehabilitation of a hamstring injury.

The most common conditions which have symptoms of pain in the hamstrings are: ● hamstring muscle strains ● posterior compartment syndrome of the thigh ● hamstring syndrome ● ischiogluteal bursitis ● adverse neuromeningeal tension ● piriformis syndrome ● lumbar spine pathology ● sacroiliac joint pathology

This article is not intended as a review of the more sinister caus- es of posterior thigh pain, such as neoplasms, overt disc protru- sions with definite signs of nerve root compression, ischial apophysitis or avulsion fractures, but these conditions are possi- ble causes and should be borne in mind.

Differential diagnosis 1. Hamstring strains Definition: A partial tear of one of the three muscles of the ham- string group (biceps femoris, semitendinosus, semimembranosus) (Fig.1) Cause: Typically caused during eccentric muscle contraction, when the tension generated by the muscle is insufficient to counter and control the force bringing about the lengthening of the muscle and a tear of muscle fibres results

6 SportEX

Presentation: The patient complains of sudden sharp pain, which often comes on while sprinting or jumping. The pain is frequently localised with the injury being particularly prevalent at the muscu- lotendinous junction of biceps femoris. The patient is only able to continue activity if it is a very minor strain Assessment: The patient in the acute stages of a significant tear of the hamstring presents with an antalgic gait, unwilling to walk (or run) with a normal stride (which would require lengthening of the strained muscle). They may be able to jog at this time with a reduced stride. Bruising may be present if the degree of injury has torn both muscle fibres and the muscle’s fascial sheath creating an intermuscular haematoma. On examination there will be pain and decreased strength on an isometric muscle contraction and straight leg raise will be painfully limited. Palpable tenderness may be pre- sent most commonly at the musculo-tendinous junction Treatment/rehabilitation: The initial aim of treatment is to decrease inflammation and reduce the potentially deleterious effects of secondary tissue hypoxia; this is achieved using PRICE and electrotherapeutic modalities. An exercise programme is then carried out to improve strength (particularly eccentric) of the hamstrings and flexibility (see p11).

2. Posterior compartment syndrome of the thigh Definition: Ischaemic (stitch-like) pain due to raised intra-com- partmental pressure Cause: Pain as a result of reduced blood flow in the posterior thigh caused by an increase in intra-compartment pressure in the