Name: Mr D
Reason for consultation: Right sided hamstring pain on athletic activity
Mr D is a high-level sprinter, specialising in 60m and 100m events. He has had a significant left hamstring tear previously, but was not a candidate for surgery.
For the last 3 years, Mr D has experienced right hamstring pain whilst training. This is not severe, but does sometimes prevent Mr D from training at proper intensity.
Mr D has had numerous sessions of physiotherapy with no significant change in his symptoms.
On presentation, Mr D pointed to the outside aspect of his lower thigh, almost behind his knee. It is very unusual for hamstring injuries to affect the lower part of the hamstring, normally affecting the upper part of the thigh.
Discussion with Mr D revealed that rest can be an aggravating factor, with symptoms magnified on returning to activity after a break. Driving is also thought to be an aggravating factor.
On examination, Mr D appears to be in outstanding physical condition. He has excellent muscle development throughout, with surprisingly good coordination and control of muscle activity.
Hamstring flexibility is good, and stress tests are not provocative. There is some stiffness affecting his left sacroiliac joint, likely to be a result of the previous left hamstring tear.
Because of the close relationship between the sacroiliac joints and hip extensors, it is plausible that altered sacroiliac mechanics are affecting Mr D’s right hamstring, but this does not explain the negative findings on provocative testing.
Because of the location of Mr D’s pain, knee examination was also conducted. This was generally unremarkable, but palpation of one muscle was extremely painful.
Popliteus is a muscle that rotates the knee joint, or prevents the knee from being rotated. Irritation or damage to the popliteus gives rise to pain on the outside aspect of the lower posterior thigh.
It is an uncommon diagnosis, but sprinters are at higher risk of popliteal injuries.
Treatment was offered aimed at relieving pain from the popliteus, alongside rehabilitation to decrease the strain on this tissue and improve its resilience. Treatment and rehabilitation aimed at restoring normal sacroiliac joint mechanics was also offered.
Treatment consisted of sacroliac joint mobilisation and manipulation, knee manipulation and popliteus dry-needling.
Rehabilitation involved mostly single leg exercises, with additional challenge from using unstable services.
Mr D was advised to reduce the volume and intensity of track training for 3 weeks, before gradually returning to full intensity.
After his first session, Mr D reported total improvement in his symptoms, with no pain at all on training, albeit training was at lower than normal intensity.
With gradual progression and admirable dedication to his rehabilitation programme, Mr D has now (6 months after presentation) been training at full intensity for 4 months with no return of symptoms.
Mr D’s case is a perfect example of how full and comprehensive physical examination is essential to be able to provide effective treatment, but also how rehabilitation is one of the most important contributors to full recovery.
Without appropriate rehabilitation, Mr D would almost certainly have relapsed on resuming full activity.
