Student no: 13043844
Word count: 3,244
Advanced Osteopathic Evaluation and Patient Management Student no: 13043844
Word count: 3,244
Student no: 13043844
Word count: 3,244
1.0 Introduction This essay provides the reader with a complete model of holistic rehabilitation; exploring reasoning and corroborating with research. The focus will be on providing an evidence based treatment plan of the patient’s condition. The patient’s name is Aase. She is a 28 year old female sweep rower presenting with left posterior thigh pain. The onset was 3 weeks ago following a walking holiday. The pain came on gradually increasing over a week period. Aase’s rowing team must be ready for a national team-profiling day in 8 weeks time (See Appendix 1). 1.1 Working Diagnosis “Left hamstring strain due to reduced left SIJ movement and poor Lumbo pelvic motion.” Hamstring strains are some of the most common injuries in sport today (Liu et al 2012)(Järvinen et al 2013)(Ramesh & Sivasankar 2014). The hamstring group consists of three muscles (from medial to lateral) Semimembranosus, semitendinosis and bicep femoris their anatomy dictate their function and susceptibility to injury (Table 1). Most hamstring strains are at the proximal musculotendous junction and occur during the terminal swing phase of gait (Sherry et al 2011) (Guex & Millet 2013). Aase’s presentation is indicative of this, as pain is felt during swing phase of gait and was noticed following a walking holiday. In addition, passive internal rotation at the knee being reduced indicates that it is bicep femoris which is the most pathological muscle. Table 1 - Hamstring anatomy (Marieb & Hoehn 2014)
Muscle Semimembranosus
Semitendinosus
Bicep Femoris
Origin/Insertion Origin: Ischial tuberosity Insertion: Medial condyle of tibia; via oblique popliteal ligament to lateral condyle of femur Origin: ischial tuberosity in common with long head of bicep femoris Insertion: medial aspect of upper tibial shaft Origin: (long head) Ischial tuberosity (Short head) linea aspera, lateral supracondylar line and distal femur. Insertion: Head of fibula and lateral condyle of femur via common tendon.
Function Extends thigh, flexes knee and medially rotates leg.
Extends thigh, flexes knee and medially rotates leg.
Extends thigh, flexes knee and laterally rotates leg.
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2.1 - Biomechanics 2.1.1 - Walking Mechanics As the injury’s onset is speculated to be during a walking holiday, and Aase experiences pain during swing phase, the biomechanics of gait will be explored, before moving to rowing mechanics.
Figure 1 - taken from Heiderscheit et al (2010) [A] depicting anatomy of hamstring group. [B] During swing phase of running the hamstrings are active, stretched and absorbing energy from leg deceleration increasing chances of strain.
As shown in figure 1B the hamstrings have a role in the deceleration of the tibia during the swing phase of gait, this prevents the knee from hyperextending (Palastanga 2006). Thoracic spine rotation is vital in walking, as one leg is in the swing phase, the pelvis will rotate also, but to keep the head facing forward cervical rotation needs to take place. T7-8 is the pivot point where segments below and above move in opposite directions of rotation (Palastanga 2006). If Aase’s rotation is restricted then other structures will compensate. In Aase’s case her hamstrings will of stretched further during swing phase, heel strike and midstance before initiating their contraction at a compromised length. 2.1.2 - Rowing Mechanics A hamstring strain is not a typical injury in rowing. However it’s occurrence can greatly affect the rower’s performance, and certain phases of the stroke can present a vulnerability to reinjury (Hosea & Hannafin 2012). The first biomechanical specification which needs to be made is that Aase is a sweep rower working in a team of four. Sweep rowers use only one oar, the other type is sculling, where rowers utilise two oars (Steer et al 2006)(Hosea & Hannafin 2012). The rowing stroke is a cyclic set of phases (Figure 2). It begins with ‘the finish’ where the knees in full extension, relatively extended hips and shoulders and elbows flexed into the body (Figure 2A). The elbows extend as the shoulders flex allowing the hands to move away
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from the body, the hips and trunk flex forward, this marks the recovery phase (Figure 2B, 2C). As the hands pass the knees the legs begin to flex to approximately 115°. Here the hips are fully flexed and the elbows are fully extended, and the oar is placed into the water; this marks ‘the catch’ phase (Figure 2D). The next and final phase is the drive, the legs push the body backward as the back and arms transmit this force into the oar (Figure 2E, 2F).
Figure 2 - Phases of the rowing stroke: A) The finish. B) Early recovery. C) Late recovery. D) The catch. E) Early drive. F) Late drive. Taken from (Hosea & Hannafin 2012).
During every stroke Aase’s body will undergo external forces at three points: 1. The handle of the oar. 2. The foot stretcher 3. The boat’s seat. The force at the handle is vital to produce the horizontal velocity of the boat, but this force upon the handle is dependent on the ability to produce high forces through knee extension into the foot stretcher (Buckeridge et al 2014). This phase of knee extension is called the drive phase (illustrated in figure 2; phases E and F). When Aase begins the drive phase her asymmetrical force will result in mechanical compensations to keep the handle’s trajectory.
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These compensations are pelvic and lumbar rotations and side bending in the lumbar and thoracic spine (Buckeridge et al 2014)(Ebert et al 2014)(Strahan et al 2011). Aase’s ‘catch’ phase will rely too much on lumbar flexion due to her reduction in hip flexion and left SIJ restriction. This will put the hamstrings under asymmetric load, with increased tension on the left hamstring. The final point of force in a mechanically efficient stroke should be through the seat. The pressure should be equally distributed due to the symmetry in force generation through the legs. However due to Aase’s asymmetrical loading through her lower extremity her centre of pressure will be affected, which can lead to back pain (Hosea & Hannafin 2012). Sweep rowers have asymmetrical movement patterns, as their outside arm must undergo a larger arch than the inner one due to their distance from the fulcrum. It has been noted that this also results in a lateral dominance in the lower extremities (Riganas et al 2010).
Figure 3 - Posterior oblique sling(Taken from Panayi 2010)
2.2 - Tissue Damage and Healing 2.2.1 - Grading Strains In muscular strains the myofibres, basal lamina, mysial sheaths and blood vessels contained in the endo or perimysium are torn. However the extent of this determines their clinical severity and as a result grade. Stoller (2007) (cited in Malliaropoulos 2012) classified strains by MRI (table 2), this grading system is the model widely used today. Table 2 - Hamstring strain gradingClassification
Grade 0 Grade 1 Grade 2 Grade 3 2.2.2 - Phases of Tissue Recovery
Findings Healthy tissue, no pathological findings Muscle oedema without tissue tear. Partial muscle tear. Complete muscle tear.
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The two main factors ensuring skeletal muscle recovery are resident satellite cells and inflammatory cells from the blood (Relaix & Zammit 2012). The healing process can be characterised by 4 distinct stages: hemostasis, inflammation, proliferation and remodelling (Diegelmann & Evans 2004). Kharraz et al (2013) state that the post injury inflammatory stage is a vital part of recovery, that allows for muscle repair, regeneration and growth. However Tidball (2005) adds that some inflammatory processes will all so inhibit muscle recovery, and instead promote fibrotic changes to the muscle fibres. Lederman(2005) suggests that clinicians can help aid recovery through manual therapy, using different techniques at the different stages of healing (See graph below).
Figure 1 - Guide to manual therapy treatment when considering phases of healing (Taken from Lederman 2005)
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3.0 - Predisposing/Maintaining Factors 3.1 - Predisposing Factors Table 3
Predisposing Factors Left sacroiliac joint (SIJ) restriction
Justification The bicep femoris long head is continuous with the superficial and distal part of the sacrotuberous ligament, which traverses the SIJ and feeds into the thoracolumbar fascia, this is part of the posterior oblique sling (Hoskins & Pollard 2005a)(Willard et al 2012). Sweep rowers often have muscular imbalances due to their asymmetrical techniques (Hosea & Hannafin 2012)(Riganas et al 2010) It is through these asymmetries and other predisposing factors which has caused Aase to have a restricted left SIJ. Mendiguchia & Brughelli (2011) explained how SIJ restrictions can predispose hamstring injury, as the force cannot be exerted through the posterior kinetic chain and is instead loaded into the hamstring. Over time this can lead to asymmetrical fatigue, which increases the chance of strain further (Heiderscheit et al 2010)(Pagorek et al 2011).
Reduced lumbopelvic and thoracic mobility
It is through the fascial connections of the posterior oblique sling (Willard et al 2012) that the lumbopelvic mobility can dictate the tension at the hamstrings and in turn prime them for injury (Heiderscheit et al 2010)(Panayi 2010). Aase’s restricted thoracic spine means the TFL cannot transmit it force effectively. Compensation will then come from increasing stride length, increased pelvic movement and anteversion at the hip (Cassella et al 2013). As the SIJ is restricted the majority of the compensation will come from stride length and hip anteversion. This leaves the hamstrings working at a compromised length and therefore increasing probability of injury (Pagorek et al 2011).
Lumbar Scoliosis
Aase’s scoliosis is likely sequlae to sweep rowing, as Riganas et al (2010) explains, the repetitive lateral dominance in their stroke techniques promote somatic asymmetries.
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The presence of a scoliosis is not necessarily a predisposing factor as Peterson-Kendall et al (2005) found that the prevalence of left concave lumbar functional scolioses in right handed individuals is common and usually asymptomatic. Nevertheless a scoliosis could present a disruption to the kinetic chain of force leading to an imbalanced force distribution in Aase’s rowing stroke, and gait. Impacting her rowing performance and predisposing her to injury. Left fibula head restriction and Left peroneal When looking at the anatomy (Table 1) it is tightness apparent that a restriction in the tibiofibula joint will ultimately affect the bicep femoris’ elasticity and capacity for loading (Bozkurt et al 2003).It is at the tibiofibula joint that the strong fascial ties between the peroneals and bicep femoris meet, if the peroneal musculature is tight (as seen in Aase) further tension is fed through the fascia into bicep femoris (Hoskins & Pollard 2005a). As sequlae to the peroneal tension restrictions in the ankle and midfoot will cause a similar kinetic restriction. Left hip restriction
Fatigue
Hamstring weakness
This restriction may be a result of the tightening of the hamstrings, but it could be an anterior capsular restriction which will have the tendency to facilitate iliopsoas and inhibit gluteus maximus (Panayi 2010). This inhibition further loads the hamstrings synergists increasing chances of injury (Elphinston 2008). As Aase trains 8 times a week, it is likely that during her walking holiday she was already fatigued. A fatigued muscle has been found to be much more susceptible to injury (Heiderscheit et al 2010)(Pagorek et al 2011). Fatigue causes a decrease in neuromuscular control in the trunk and hamstrings (Gorelick et al 2003)(Melnyk & Gollhofer 2007). Thus further increasing the likelihood of a muscle strain (Heiderscheit et al 2010). Assuming Aase’s is fatigued on the walking holiday (Parkin et al 2001) Riganas et al
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(2010)found that sweep rowers often present with stronger oarside knee flexors and extensors. Which means that the other side is relatively weak, assuming this is Aase’s left side, it’s likely that her left hamstring was more fatigued and inelastic which made it more susceptible to injury(Heiderscheit et al 2010)(Pagorek et al 2011). Muscular weakness could caused by Aase’s restrictions in the hip (Panayi 2010). 3.2 - Maintaining Factors Table 4
Maintaining Factors Ibuprofen
Acute lordosis
Peroneals Muscle weakness Fibula restriction Stripping of ITB and hamstrings
Justification The consecutive use of NSAIDs for longer than 7 days reduces the body’s capacity to repair muscle through the deactivation of satellite cells and inhibition of growth factor production (Baoge et al 2012). Baoge et al (2012) recommends the use of NSAIDs 48 hours after the initial injury to reduce pain and the early inflammatory response, earlier than this can effect the chemotaxis (movement of cells) necessary for repair and remodelling. An acute lordosis often correlates with an anteriorisation of the pelvis, increases the loading on the hamstrings tendons at the ischial tuberosity. Increased loading is a predisposing and maintaining factor of injury (Panayi 2010). The hamstrings are key in orientating the pelvis and lumbar spine. They effect the anteroposterior tilt of the pelvis with assistance of the abdominal muscles and gluteus maximus, this in turn will change the lordosis of the lumbar spine (Palastanga 2006). Gracovetsky (2008) states the most important factor in controlling efficiency of force transmission through the lumbodorsal fascia is the lordosis. See Table 3 - Predisposing Factors See Table 3 - Predisposing Factors See Table 3 - Predisposing Factors
Although some research states deep ‘stripping’ soft tissue work into the ITB and hamstrings
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can be effective (Forman et al 2014). If the therapist was inducing too much force, too soon after injury it could be maintaining Aase’s strain through micro trauma to the effected musculature and fascia. Reduced lumbopelvic and thoracic mobility Psychological
See Table 3 - Predisposing Factors
Wiese-Bjornstal (2010) states that the psychology and emotional state of an athlete has a direct affect on their ability to recover. Especially as Aase will be nervous about her upcoming national team-profiling day.
4.0 - Rehabilitation 4.0.1 - Phases Mendiguchia & Brughelli (2011) highlighted three main stages of rehabilitation when treating an acute hamstring strain. The phases parallel Diegelmann & Evans (2004) phases of tissue healing, discussed in 2.2 (stated in brackets next to them for clarification). The management plan will follow these phases, utilising current evidence to aid Aase’s progression through them and back to rowing. The three phases are: 1. the acute phase (hemostasis and inflammatory) 2. the sub-acute/rehabilitation phase (proliferation) 3. the functional phase. (remodelling) Aase’s presentation states the holiday was three weeks ago, but the pain has been worsening in the last week. This suggests her hamstring strain was undergoing these phases of recovery in the past weeks but is being re-injured. Heiderscheit et al (2010) identified three factors which explain why hamstring strains can reoccur : 1. Enduring weakness of the musculature 2. Reduced flexibility in the musculotendon unit 3. Changes to biomechanics and motor patterns of functional movements. By addressing these three factors in Aase’s management plan the likelihood of re-injury will be decreased, allowing for a full recovery and reintroduction to rowing. This rehabilitation plan will be following the Heiderscheit et al (2010) criteria for phase progression. As Aase feels pain during gait she is still in the first acute phase of injury. The criteria which needs to be met for progression is as follows: 1. Normal gait without pain 2. Slow jogging without pain 3. Isometric contraction at 60% strength during prone with knee flexed to 90°. Lederman (2005) states that the clinicians primary role during the first phase is based on reducing pain and swelling during the week following injury. It is widely agreed that at this stage the RICE (Rest, Ice, Compression and Elevation) routine, immobilisation followed by gentle mobilisations is the best course of action (Heiderscheit et al 2010)(Hunter & Speed 2007)(Tidball 2005). So as to aid formation of the granulation tissue matrix and inhibit formation of scar tissue (Hoskins & Pollard 2005a). Although Aase is still in the acute phase, immobilisation and RICE is no longer necessary. This is because the initial hemostasis has alleviated (Diegelmann & Evans 2004). The initial treatment will be
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dependent on the current severity and grading of Aase’s strain and the tissue quality of the hamstrings. The progression to stage three will be achieved when Aase can: 1. Isometric contraction with full strength during prone with knee flexed to 90°. 2. Running forwards and backwards at 50% speed without pain. The progression to return to sport is the hardest one to make, due to the reoccurring nature of hamstring strains (Mendiguchia & Brughelli 2011). The best possible criteria is when Aase can achieve full range of motion, full strength and perform functional abilities such as running jumping and squatting without pain (Heiderscheit et al 2010). 4.1 - Mobilisation and Manipulation During the initial inflammatory phase of injury slow controlled mobilisations can promote myofibril alignment and regeneration, inhibition of scar tissue and improved blood supply and drainage of the area. Therefore increasing the elasticity and strength of the recovering muscle (Hoskins & Pollard 2005b) (Lederman 2005) (Mendiguchia & Brughelli 2011). It must be noted that when treating a joint, the restrictions must be addressed before strengthening the muscles. This is because mechanoreceptors in the joint will cause muscular inhibition of the prime movers at that joint. This reflex is to prevent the joint surpassing its structural restrictions. Therefore there is little use strengthening a muscle that is being regularly inhibited (Panayi 2010). 4.1.1 - Spinal The restrictions found in the thoracic spine effects the hamstrings via thoracolumbar fascia (TLF). The TLF is continuous with paraspinal fascia in the thoracic region, which then links to the hamstrings through the sacrotuberous ligament (Willard et al 2012). These fascial connections called slings are vital in force dispersion. Aase’s posterior oblique sling (Figure 3) will not be able to transmit force effectively, due to her restricted rotation through her thoracic spine (2.1.1). Using osteopathic mobilisations and manipulations is an effective technique for improving joint motion, and as a result reducing hamstring loading (DiGiovanna 2005)(Pagorek et al 2011). The thoracic mobilisations will be into extension and rotation to reduce Aase’s extended kyphosis and simultaneously increase rotation into the restricted segments. 4.1.2 - Sacroiliac The SIJ can be restricted by the posterior oblique sling which passes over it (Figure 3). This sling can be restricted through a contracture of biceps femoris which attaches into the sacrotuberous ligament and then the TLF (Willard et al 2012). This restriction is a likely sequlae to Aase’s hamstring strain, and is a maintaining factor of the injury. By freeing restrictions in the sacroiliac joint a tensile release will occur through the myofascial system improving force transmission through the TFL and decreasing hamstring loads (Mendiguchia & Brughelli 2011). Panayi (2010) found that SIJ mobilisation and manipulation stimulates joint proprioception and activates gluteus maximus and the hamstrings.
4.1.3 - Hip
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The hip mobilisation will be coupled with the knee and SIJ, and are primarily a gentle mobilisation of the hamstrings, allowing for full control of stretch by orientating both origin and insertion. 4.1.4 - Knee When addressing the anatomy it is clear that knee mobilisations will specify movement to the distal portion of the hamstrings (Table 1). Using the knee can be a useful modifying tool for hamstring stretches (Askling et al 2014). 4.1.5 - Fibula Head A restriction in the tibiofibula joint affects the bicep femoris’ elasticity and capacity for loading (Bozkurt et al 2003). Lederman (2005) explains that fibula head restrictions respond well to manipulation, and recommends it as a technique. 4.2 - Soft tissue Techniques During the initial inflammatory phase of injury gentle soft tissue techniques such as effleurage are recommended (Lederman 2005). The techniques will get progressively more direct and aggressive. Soft tissue is used to increase blood flow and drainage (effleurage) to the hamstring musculature, release fascial tension (petrissage and inhibition) and break down fibrosis (friction) (Ylinen & Cash 2011)(Best et al 2012)(Forman et al 2014)(Lederman 2005). Inflammatory cells such as macrophages are delivered through the blood, these are thought to play the greatest part in the repair process (Kharraz et al 2013). Research by Arnold et al (2007) confirms that when blood supply was reduced so was the ability of muscular repair. 4.2.1 - Psoas Inhibiton It has been suggested that the lumbopelvic musculature is an important consideration when addressing hamstring strains (Mendiguchia et al 2011)(Sherry & Best 2004). It can be both a predisposing factor or a biomechanical response to injury (see 3.1 and 3.2) (Heiderscheit et al 2010) (Opar et al 2012). Psoas’ role is both a hip flexor and spinal stabiliser (Marieb & Hoehn 2014)(Regev et al 2011). Psoas tightness is common in rowers (Hosea & Hannafin 2012). Treating psoas will increase neuromuscular activation, therefore stability of the lordosis and pelvic control (DiGiovanna 2005)(Gracovetsky 2008). If the deep hip flexors are firing well then less strain will be on the quadriceps and as a result a reduction in antagonistic loading of the hamstrings (Chaitow And Franke 2013). 4.3 - Muscle Energy Techniques (METs) METs will be used in order to reduce scar tissue by reducing collagen cross link formation and facilitate functional muscular remodelling (Chaitow And Franke 2013)(Gibbons 2011)(Lederman 2005). This can prevent recurrence of injury and muscular fibrosis by restoring the previous structure rather than one of reduced mobility. Askling et al (2014) concluded that a rehabilitation model which focused on lengthening hamstring strains is more effective than a conventional protocol. 4.3.1 - Reciprocal Inhibition (RI) As Aase’s hamstring is too acute to work on directly, some of the tension and associated spasm can be reduced through contraction of the quadriceps (Chaitow And Franke 2013). Gibbons (2011) states that RI is an effective treatment for working on acute muscles in spasm. It is important when working with such acute musculature strains to have good explanation and communication to avoid further injury.
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4.3.2 - Post Isometric Relaxation (PIR) When Aase reaches the sub-acute and functional phases PIR METs can be used to stretch and strengthen her hamstrings. These will progress in force relative to the increasing capabilities of the muscle (Chaitow And Franke 2013)(Gibbons 2011). Recent research by Ramesh & Sivasankar (2014) showed that post isometric relaxation (PIR) METs were most effective in increasing flexibility in the hamstrings when compared to standard stretch routines. 4.3.3 - Active Posterior Oblique Myofascial Stretch The principles of this stretch is similar to an MET but rather than focusing on a specific muscle it is on the chain of muscles which work interdependently (Chaitow And Franke 2013). The posterior oblique sling (seen in figure 3) is restricted at several points (discussed in 3.1 and 3.2) by working globally on this chain it’s possible to promote functionality and activation of the musculature involved (Panayi 2010). Sherry & Best (2004) stated that isolated hamstring stretches is not an effective rehabilitation model in comparison to exercises promoting agility and trunk stabilisation. These findings highlight the importance of a multifaceted rehabilitation program when assisting athletes in their return to sports and preventing injury. 4.4 - Nutrition and drugs. Wound healing is a complex cellular process which relies on essential nutrients to restore function. Nutrition must be specified to the individual so it would be advantageous for Aase to have a blood test prior to the formation of a diet plan. However the essential nutrients which Aase should have in her diet for recovery are; proteins, fatty acids, vitamin C, zinc and iron (Wild et al 2011). Aase should stop taking ibuprofen. Ibuprofen is a non-steriodal anti-inflammatory drug (NSAID). The consecutive use of NSAIDs for longer than 7 days reduces the body’s capacity to repair muscle through the deactivation of satellite cells and inhibition of growth factor production (Baoge et al 2012). Baoge et al (2012) recommends the use of NSAIDs 48 hours after the initial injury to reduce pain and the early inflammatory response, earlier than this can effect the chemotaxis (movement of cells) necessary for repair and remodelling.
4.5 - Exercises
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Exercises are used to strengthen the musculature and develop neuromuscular control, initially these exercises need to be highly controlled and within a comfortable range. As the patient progresses through the phases exercises become more intense and dynamic (Heiderscheit et al 2010). Sherry & Best (2004) and Silder et al (2013) state the importance of exercises early in the recovery phases to limit atrophy. Table 5 - Exercises
Exercise Exercise 1 Spinal Twists
Details
Justification
Aase should sit and cross one leg over the other, This exercise is a gentle putting her foot flat next to her knee. Then begin to easily controlled exercise for rotate her trunk as far as comfortable, while stretching the posterior keeping her spine straight. Then rotate the head to fascial slings, paraspinal look over the side of which the leg is flexed.
muscles and mobilising rotational restrictions in the thoracic spine. As a secondary to this a static hamstring stretch can be included in the exercise. This exercise can be performed while the strain is relatively acute, as it shouldn't exacerbate the hamstrings when done correctly.
Exercise 2 The Extender
Taken from (Ince et al 2006). Aase should hold the injured leg at 90° and slowly This exercise is a gentle and extend the knee to the point just before pain is felt. controlled stretching exercise
which is useful in the acute and sub-acute phases to build Aase’s confidence and proprioceptive control. By giving complete control to the patient they can understand their limits of motion and pain before progressing to more technical and challenging Taken from Askling et al (2014) exercises. This exercise begins with Aase on her side with her The rotating plank exercise Exercise 3 Rotating Planks forearm under her shoulders and legs stacked and increases trunk parallel, by contracting her abdominals Aase will lift proprioception, stabilisation her hips to assume position A. This position should and pelvic neuromuscular be held with the body and head in a straight line for control (Sherry et al 2011). 2 seconds. Next by rotating the trunk toward the This exercise is again ground without letting the pelvis drop (position B) and placing the other forearm on the floor (position valuable in the acute phases
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C), continue to twist till Aase is in another side of rehabilitation as it bridge facing the opposite direction (position D). shouldn’t exacerbate the Hold for 2 seconds and repeat in reverse. hamstrings.
Taken from Sherry et al (2011) From standing begin closed chain flexion at the hip This exercise is a good body Exercise 4 of the injured leg while stretching the arms forward weight eccentric hamstring Single Leg and maximal hip extension of the lifted leg. The exercise allowing controlled Deadlifts spine and pelvis must be kept linear and (Sherry et al stretch while all so activating horizontal. The supporting knee must be slightly 2011)/The trunk and pelvis control. First flexed. As Aase may be unfamiliar with this Diver (Askling in the acute and sub-acute relatively complicated exercise it’s best to start et al 2014) phases body weight can be slowly and without weights.
used, when Aase moves into remodelling phase weights can be added and then increased (Askling et al 2014) (Sherry et al 2011).
Exercise 5 Eccentric box jumps
Taken from Sherry et al (2011) Step up onto the box (A), then jump (B) into a deep Another eccentric hamstring squat position (C). Stand up slowly and repeat. exercise that utilises Aase’s
body weight. This exercise utilises bilateral contraction and stabilisation of the lower extremity simulating ‘the drive’ rowing stroke (illustrated in figure 2; phases E and F) and prepares for the more difficult Nordic curl exercise.
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Exercise 6 Eccentric Nordic Curl
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Taken from Sherry et al (2011) Aase needs to kneel with her ankles secured and Nordic eccentric hamstring padding under her knees. From an upright position exercises have been showed she needs to extend at the knees as slowly as to be effective in the possible while keeping her body straight. At first prevention of hamstring resistance bands can be used to aid a slow strains (Guex & Millet 2013) controlled descent.
Taken from van der Horst et al (2014)
(van der Horst et al 2014). Sherry et al (2011) criticise Nordic curls because they do not utilise muscle function in a unilateral asymmetric fashion, and is not functionally relevant to most sport. However Nordic curls are specified for rowing, in which the leg movements are symmetrical and bilateral (see figure 2) (van der Horst et al 2014).
5.0 - Plan Rehabilitation Phase Technique/Exercise Details Acute Phase (hemostasis and inflammatory) Week 1-2
Considerations/Justification
Thoracic and lumbar Aase prone; Bilateral lumbar rotation spine mobilisations harmonics and mobilisation. Thoracic sphinx mobilisation, bilateral. Aase side-lying; bilateral foraminal gaping. All mobilisations must be controlled and without hamstring pain.
Considerations: Manipulation only Considerations: Not to hyperextend Aase’s acute lordosis by putting a pillow under Aase’s stomach when patient is prone or mobilise patient sitting. Justifications: see 4.1 and 4.1.1
Soft Tissue Techniques
Aase prone; Slow and gentle upward effleurage of the left posterior thigh. Friction and inhibition on areas of fibrosis and trigger points in the gluteals, lumbar erector spinae and triceps surae. Aase supine; petrissage into left quadriceps, friction left peroneal group and active inhibition of psoas, bilateral.
Considerations: Inform patient that they may feel sore post treatment. within the limits of the hamstring musculature. Not to hyperextend Aase’s acute lordosis by putting a pillow under Aase’s stomach when patient is prone Justifications: see 4.2 and 4.2.1
Muscle Energy Techniques (METs)
Aase supine; Reciprocal inhibition MET of the left hamstrings
Justification: see 4.3.1
Fibula head and foot Aase supine; mobilisations to left fibula head, mobilisations and tibiofibula interosseous membrane. Left ankle and midfoot mobilisations.
Justification: see 4.1.5
Global mobilisations Aase supine; Left SIJ sheering while inducing of SIJ, hip, knee and hip and knee flexion, within limits of pain. lumbar spine Aase side-lying; specific left SIJ mobilisation.
Justifications: see 4.1.2, 4.1.3, 4.1.4 and 4.1.1
Spinal Twist Exercise
To be completed twice every day, both side and to be held for 30 seconds. Details: See Table 5 Exercise 1
Justification: see table 5
The Extender exercise
with 12 repetitions while in the acute and sub- Justification: see table 5 acute phases. Details: See Table 5 Exercise 2
Advise on Nutrition. Advise on private blood test for deficiencies, then specify diet plan accordingly.
Justification: see 4.4
Sub-acute phase (proliferation) Week 3-5
Left SI, thoracic and Aase side-lying; Lumbar roll, SIJ manipulation Aase supine; HVT (A/P thrust) to lower lumbar manipulations thoracic segments
Considerations: Manipulation only necessary if restrictions are present as can be detrimental to strengthening exercises (Panayi 2010) See 4.1. Add local lumbar side bending to lumbar roll to decrease moment on scoliosis. Justifications: See 4.1.1 and 4.1.2
Long lever fascial stretches of posterior oblique sling.
Aase semi sims; pelvis turned to the right side using left leg as lever to increase stretch and getting patients right arm into full abduction.
Considerations: Putting a pillow under Aase’s stomach, to avoid hyperextension. Keep communication as practitioner cannot see expressions of pain in this position. Justification: see 4.3.3
Muscle Energy Technique
Aase supine; Post isometric relaxation MET of hamstrings.
Considerations: Start conservatively as tissues will still be vulnerable Justification: see 4.3.2
Rotating Plank Exercise
*To be completed once a day, with 5 rotations each time. Details: See Table 5 Exercise 3
Movements must be slow and controlled.
Single leg dead lift no weights
*To be completed twice every day, 7 controlled reps, 3 sets. Details: See Table 5 Exercise 4
Focus on slow movements to perfect technique
Justification: see table 5
Justification: see table 5
Eccentric box jumps *To be completed twice every day, 7 reps, 3 sets. Start with Jumping on the spot to assess Details: See Table 5 Exercise 5 tissue vulnerability. Justification: see table 5 Functional phase
Repeat sub-acute
Repeat treatment with increased force and
Justification: see 4.0.1
(remodelling) Week 6- 8
phase
repetitions.
Direct soft tissue
Direct petrissage, friction and inhibition to the hamstrings
Justification: see 4.2
Single leg dead lift with weights
*To complete, 7 repetitions, 3 sets. Details: See Table 5 Exercise 4
The weights given will be dependent on Aase’s current strength, they must be challenging but not overwhelming. Justification: see table 5
Nordic Curls
*To complete 5 repetitions, 2 sets. Justification: see table 5 Details: See Table 5 Exercise 6 *Repetitions given in Table 6 are only recommendations. If Aase feels sore and weak the day after strengthening exercises, ice should be applied and repetitions should be reduced, to give a more comfortable progression of strength and neuromuscular control (Heiderscheit et al 2010).
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6.0 - Discussion The treatment and rehabilitation of sports professionals in the literature is condition orientated, however an osteopathic rehabilitation must include all the holistic considerations which could influence Aase’s recovery. An osteopathic rehabilitation comes from viewing the body as a unit, and understanding the psychological, biomechanical and nutritional aspects to recovery (Parsons and Marcer 2006). Viewing injury as purely mechanical is a reductionist view, Wood (2004) confirms this by finding increased emotional stress leads to musculoskeletal sensitisation. By addressing all of these factors we can treat holistically to facilitate the Aase's ability to heal herself (Parsons and Marcer 2006). It must also be considered that if conservative treatment isn't effective it may be essential to reassess the patient's condition and re-diagnose (DiGiovanna 2005). Potentially even referring to another more specialised health care practitioner (GOsC 2012). It is important to include Aase in the development of this treatment plan. By explaining the situation to her she can decide to take an active role in her own plan and give consent to what she sees fit (GOsC 2012). Parascandola et al (2002) highlighted the challenges of managing uncertainty through consent, expressing the need to include the patient when developing a treatment plan. However as the practitioner is the one who informs the patient a bias of past experience and knowledge may still skew the decision and the patients needs may still not be met (Cardarelli & Chiapa 2007). 7.0 - Conclusion Aase’s rehabilitation is a multifaceted model which through utilising recent literature, following the osteopathic method, and understanding Aase’s own requirements as an athlete and patient can aid recovery and prevent re-injury. Through knowledge of tissue physiology (2.2) we as manual practitioners can promote health by knowing when to utilise joint mobilisations, manipulations, soft tissue techniques and METs to best aid patient recovery. Aase’s progression through the phases of rehabilitation and eventually back to sport must be observed and regulated to prevent chance of re-injury. The clinicians role, although beneficial, is limited, the rest is down to Aase’s own discipline in completing the exercises and adjusting her nutrition. If there are issues with communication, general health or emotional stress during this period it is essential to alter the plan accordingly, so that Aase feels in control and motivated to recover. If Aase follows the plan set (5.0) and takes an active role in her recovery she should be able to return to rowing mentally primed and physically ready for her teams national profiling day.
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Appendix 1 Case Scenario A 28 year old (female) rower presents with a high level of pain in the left hamstring area. This came on 3 weeks ago following a walking holiday, there was no incident at onset, and the pain got slowly worse over a week period. She describes it as a tight feeling with pain in the mid thigh on the leg swing phase of the gait cycle. The pain level is high in the morning and again late afternoon, but does not affect her sleep or routine daily activities. She reports taking ibuprofen, 2000mg per day for around 2 weeks but it has had little to no effect. She had been to a sports massage therapist who said it was her hamstrings and ITB, which she proceeded to ‘strip out’ on several occasions but to no long term effect. She had also recommended a foam roller which she had tried but again to no long term effect. She is an active person who, before this Injury, was training for rowing 8 times a week as part of a quad. She has not had this before, but about a year ago she suffered with lower back pain which lasted for around 1 month which she saught some Osteopathic treatment for. The Osteopath just said that she had ‘some restricted segments’. Osteopathic Examination The patient has good general muscle tone and development. She has an athletic build and a BMI of around 26. She has a long back with an extended thoracic kyphosis and an acute lumbar lordosis at L3 to S1. There is a distinct scoliosis concave to the left with the apex at L2. There is a distinct hitching of the left PSIS. The patient leans to the left through her torso, with a correction through the CT to the right.
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Active movement T/L spine Forward Flexion
limited due to pain in leg. Excessive lumbar spine flexion with poor hip mobility on L.
Extension
Restricted T spine discomfort upper lumbar spine
Sidebending right
Slight restriction upper L’s no pain
Sidebending left
NAD
Rotation
Mild restriction lower T’s pain limiting movement
On forward flexion the patient could only get their hands to the mid femur before the pain started in the mid left hamstrings and she feels she has to unlock the left knee. This would only enable her to get a few more cm of forward flexion though. Passive examination and Palpation Left hamstring increased tone, esp in mid section Left PSIS pain on palpation SLR left 45 degrees, right 85 degrees No shooting pain, tingling, numbness in the lower extremities Left Ischial tuberosity feels normal Lumbar spine - foraminal compression local discomfort bilaterally Passive knee: internal rotation and varum decreased Passive hip: NAD Passive foot/ankle: midfoot extension restriction Left fibular head restricted Increased tension in left peroneals. Left SIJ mild decrease in mob compared to right. Working DX Left hamstring strain due to reduced left SIJ movement and poor Lumbo pelvic motion.