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Competitive Sports/Section Articles

Fascial Hydrodissection for Chronic Hamstring Injury

Courseault, Jacques MD, CAQSM1; Kessler, Eric MD2; Moran, Alexandra MS, ATC, LAT1; Labbe, Andre PT, MOMT2

Author Information
Current Sports Medicine Reports: November 2019 - Volume 18 - Issue 11 - p 416-420
doi: 10.1249/JSR.0000000000000650
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Introduction

Hamstring muscle injuries (HMI) remain one of the most prevalent musculoskeletal injuries incurred during athletic activities at all levels (1). HMI range from muscle belly strains, complete and/or partial tendon avulsions, tendinopathies, and ruptures (2). The type of injury will often dictate the duration of rehabilitation and time to return to play (3). While avulsions tend to take longer to recover, strains also may result in prolonged disability.

Data compiled by the National Collegiate Athletic Association Injury Surveillance Program (ISP) showed that American football, track, and soccer were three of the highest at risk for HMI with an injury rate of 3.05 per 10,000 athlete exposures (AE) (4). Similarly, a 10-year study evaluated by the National Football League ISP, showed that the hamstring strains had a prevalence of 2.2 injuries per 1000 AE in practice to only be surpassed by knee sprains at a rate of 3.1 injuries/1000 AE (5). The average time of recovery ranges from 8 d to 25 d, depending on the severity and location of the injury. However, there are a subset of hamstring injuries that take longer to heal.

The hamstring muscle group includes the biceps femoris, semitendinosus, and semimembranosus. Acute hamstring strains traditionally have been classified as mild (grade I), moderate (grade II), and severe (grade III) (3,6). There is no established grading system for chronic hamstring injuries. However, there are known histological changes in the surrounding muscle fascia that may impair recovery.

Due to fascia being comprised of collagen, elastin, and fibroblast, Hedley (7) describes that sustained static positions can cause a congealing of fluid within fascial fibers within the gel matrix. It is possible that this stiffening of the colloidal nature of the fibers results in restricted motion and fascial adhesions (8,9). Scarring and fibrosis after muscle injury can impede the complete healing of muscle tissue and result in a delayed return to play.

In addition, Huard et al. (10) describe the process of muscle healing and scar tissue formation after injury. Following injury, muscle undergoes a distinct set of healing phases, consisting of degeneration, inflammation, regeneration, and fibrosis. Active muscle degeneration and inflammation occur in the first few days postinjury, whereas muscle regeneration usually occurs seven to 10 d after injury. The formation of scar tissue (fibrosis) begins between the second and third weeks postinjury, and the fibrosis increases in size over time. The formation of fibrosis appears to be the end product of the muscle repair process. If fibrosis is extensive or if fascial adhesions form, complete regeneration of muscle may not occur (10).

To address extensive fibrosis formation and fascial adhesions, we describe a fascial hydrodissection procedure that targets the nerves and gel matrix within fascial planes, resulting in decreased pain and improved hamstring motion.

Traditional Treatment of Hamstring Strains

There are few randomized control trials and high-quality prospective studies to support specific therapeutic strategies. Rest, ice, compression, elevation, immobilization, NSAIDs, corticosteroids, and physical therapy are initial treatment modalities (11). Adjunctive therapies, including moist heat, ultrasound, electrical stimulation, deep friction massage, myofascial release, and neuromobilization, also have been used, however, with minimal evidence available supporting these treatments (11). Surgery also has been indicated for total or near-total soft-tissue hamstring muscle ruptures or severe avulsions with more than 2 cm of displacement (12). To our knowledge, hamstring fascial hydrodissection has not been described in the literature.

Fascial hydrodissection has several applications in medical and surgical treatments. Introducing saline under pressure into planes of dissection has been used in reoperative therapy for adhesiolysis and also has been used to preserve perforating arteries in surgeries (13–15). Studies and case reports have investigated fascial hydrodissection as a therapy for relieving nerve entrapments by separating compressed nerves from the surrounding fascia (16,17). Fascial hydrodissection also may serve as a potential therapy for patients with chronic tendinopathy or myofascial injuries that have not responded to other therapies (18,19). Fascial hydrodissection can emerge as a potential therapeutic approach for chronic hamstring strains.

To ensure a proper diagnosis, as well as an accurate and safe injection, ultrasound imaging must be used. The use of ultrasound to evaluate musculoskeletal injuries poses a number of advantages: 1) the dynamic examination of muscles and tendons in real time, 2) a high sensitivity in the detection of small focal lesions, 3) the real-time guidance of interventional procedures with extreme precision, 4) the possibility of closely monitoring the changes of a lesion over time, 5) excellent tolerance by the patient, and 6) low cost (20). Therefore, ultrasound imaging can aid not only in diagnosing a fascial abnormality but also in needle visualization during the fascial hydrodissection procedure.

The following cases demonstrate the positive results of a fascial hydrodissection in athletes who were diagnosed with chronic HMI in which traditional therapeutic modalities did not resolve in complete resolution of symptoms.

Case Report/series

Patient 1, a 13-year-old male, in the U.S. Soccer Olympic Development Program, presented with a 6-month history of a right hamstring strain. With no remarkable medical history cited, the patient recalled experiencing a “tearing” sensation during competition. Subjectively, he denied pain at rest, but expressed experiencing pain near the proximal hamstring with sprinting and kicking. He reported that his speed and strength in the involved extremity was significantly decreased compared with his preinjury condition and other unaffected leg. He denied neurological abnormalities in the lower extremities. He experienced moderate benefit from traditional therapeutic modalities (i.e., ice, physical therapy, stretching) but symptoms did not fully resolve.

Upon physical examination, a focused neurological examination was normal. There was tenderness to palpation at the proximal semitendinosus. Right knee flexion strength was slightly weaker than the left. Active-resisted knee flexion reproduced symptoms. In the office, ultrasound imaging (GE Logiq E, 5–13 MHz linear transducer) (Fig. 1) was consistent with a hyperechoic fascial thickening (compared with contralateral side) with postacoustic shadowing (presumed calcification) at the proximal semitendinosus/adductor magnus fascial plane. After identifying the sciatic nerve, an ultrasound-guided hamstring fascial hydrodissection (3.5-inch 22-G Tuohy needle) was performed with 2 mL of 0.5% bupivicaine, 2 mL of 1% lidocaine, 1 mL of 40 mg/mL methylprednisolone, and 10 mL of normal saline mixture. Following the injection, the spinal needle was passed through the area of fascial abnormality to disrupt excessive fibrosis and the presumed calcification. Resistance was felt as the needle passed through these structures. Figure 2 shows the ultrasound image immediately after the injection. Immediate improvement in flexibility was noted by the patient, and strength and sensation testing after the injection were normal. He ambulated without difficulty. Two days following the injection, he reported a full return to practice without symptoms. At his 2-wk follow-up, he stated full resolution of pain in the hamstring and reported that he was able to play a full match with normal strength and without pain during or after competition. On physical examination, no tenderness was noted at the proximal semitendinosus, and bilateral knee flexion strength was equal. Follow-up ultrasound showed normal fascial planes without shadowing (Fig. 3). At 1 year postinjection, there was no pain or decrement in playing ability.

F1
Figure 1:
Patient 1 ultrasound prior to fascial hydrodissection therapy.
F2
Figure 2:
Patient 1 first visit, right after injection.
F3
Figure 3:
Patient 1 ultrasound at 2-wk follow-up.

Patient 2, a 17-year-old male high school football player (wide receiver) presented with a 6-wk history of a right hamstring strain. With no remarkable medical history cited, he felt his hamstring “pull” while running routes. Subjectively, he denied pain at rest, but expressed experiencing pain near the proximal hamstring with hamstring curls and squats. He denied neurological abnormalities in the lower extremities, as well as numbness, tingling, or radiation of the pain, during the visit. He experienced moderate benefit from traditional therapeutic modalities (i.e., ice, physical therapy, instrument-assisted soft-tissue mobilization, stretching, ice/heat) but symptoms did not fully resolve.

On examination, he had tenderness to palpation at the medial proximal hamstring that correlated with a fascial abnormality on ultrasound imaging between the semitendinosus and adductor magnus (Fig. 4). An ultrasound-guided hamstring fascial hydrodissection was performed (same procedure as noted in the first patient). Figure 5 shows the ultrasound image after injection.

F4
Figure 4:
Patient 2, before hydrodissection, ultrasound revealing chronic hamstring tear.
F5
Figure 5:
Patient 2 after hydrodissection.

The patient reported immediate improvement in flexibility and strength. Sensation testing was normal. He was given a return to play protocol (see below). On 1-month follow-up, the patient reported resolution of his symptoms and return to full play without limitation. He did report mild bilateral hamstring tightness that was congruent with his baseline level of tightness prior to injury and was encouraged to continue a stretching program with his athletic trainer. At 3 months, the patient continued doing well and went on to play college football.

Patient 3 is a 35-year-old female who presented with 4 wk history of left hamstring pain. Her medical history included thyroid dysfunction. She did not report a particular inciting event; however, she is very active in yoga and running. She endorsed a 3/10 achiness in the left hamstring that primarily occurs when running more than three miles. She also stated that her running endurance had drastically decreased because of discomfort. She denied any associated weakness, numbness, tingling, or radiating pain. She had no treatment for the injury, and only used home foam rolling and stretching, which provided minimal benefit.

Physical examination was significant for tenderness to palpation over the semitendinosus. The neurological examination was normal. Ultrasound showed multiple areas of hyperemia from the mid hamstring down to the distal one third of the left hamstring, with fascial thickening between the semitendinosus and adductor magnus (Fig. 6). An ultrasound-guided fascial hydrodissection of the lesion was performed in the same manner as the first two patients. Following the injection, needling was performed to disrupt excessive fibrosis (Fig. 7). The patient noted immediate improvement in pain. At 3-wk follow-up, she reported 100% improvement and was able to return to baseline running status. She denied tenderness to palpation over the semitendinosus on examination at this visit. At 6-month follow-up, she continued to report 100% improvement in symptoms and returned to running 20 miles·wk−1 without pain.

F6
Figure 6:
Patient 3 before injection.
F7
Figure 7:
Patient 3 after injection.

Discussion

Most hamstring injuries resolve with traditional treatments; however, there are a subset of chronic hamstring injuries that require invasive intervention. Chronic hamstring strains involve injury to the fascia (epimysium) of two adjacent muscles that has become fibrotic. Excessive fibrosis and gel-matrix formation between two muscles may cause pain, impairment in muscle contraction, lack of synchrony, decreased flexibility, and dysfunctional movement with adjacent muscles. Clinically, the athlete will report pain, tightness, and a decrement in physical performance.

This case series highlights three important points:

First, ultrasound should be used to further evaluate hamstring injuries. Ultrasound allows a dynamic examination of the hamstring muscle complex in real time at a relatively low cost and low health risk compared with MRI (21). In addition, ultrasound is more sensitive in recognizing a clinically relevant fascial abnormality and also is more sensitive in detecting inflammation or hypervascularity (reactive hyperemia). If interventional treatment is appropriate, the use of ultrasound will increase the accuracy of injection and decrease the risk of injury to nerve and vascular structures.

Second, chronic hamstring injuries may be the result of a fascial adhesion or scar surrounding the muscle belly. A hamstring strain that does not fully resolve results in the presence of granuloma tissue, which impairs the regeneration of muscle fibers and results in the formation of fibrous scar tissue. On ultrasound evaluation, a focal, hyperechogenic, thick, stellate epimysium is seen that correlates with the area of subjective symptoms and tenderness on ultrasound-guided palpation. In some cases, postacoustic shadowing may be seen with thick fascial abnormalities that have developed calcium deposition.

Finally, this case series highlights that an ultrasound-guided fascial hydrodissection is an effective, safe, and simple treatment of a chronic hamstring injury. In the athletes presented, a fascial hydrodissection with lidocaine, bupivicaine, normal saline, and steroid resulted in drastic improvement in symptoms and a quick return to full play within a week. Patients continued to deny further complication or reinjury at follow-up.

The physician performing this procedure must be an experienced ultrasonographer. Identification of an abnormality is important; however, the identification of structures that may cause harm to the patient if injected also should be safely identified. In the hamstring, the sciatic nerve can easily be mistaken for a fascial adhesion. Therefore, the sciatic nerve should be identified and marked superficially on the patient to avoid injury. Also, anomalous nerve or vascular branches should be identified and avoided. The physician also must be able to recognize other potential abnormalities before intervening, such as a tumor or abscess.

Experience with myofascial or trigger point injections also is necessary. Knowledge of potential adverse effects of myofascial injections related to needle entry into skin, as well as potential side effects from medications is important. Potential complications include infection, excessive bleeding, hematoma formation, vasovagal response, lidocaine or bupivicaine toxicity, fat atrophy, skin discoloration, and postinjection flare.

Physicians specialized in physical medicine and rehabilitation, orthopedics, or sports medicine tend to have the most experience in injecting musculoskeletal structures and are likely best trained to perform a hamstring fascial hydrodissection.

Finally, a posthydrodissection hamstring rehabilitation protocol must follow a hamstring fascial hydrodissection to allow frequent monitoring of healing and to restore normal hamstring flexibility and strength to prevent reinjury (11). See below for the rehabilitation protocol used for the patients following the fascial hydrodissection treatments.

Hamstring Fascial Hydrodissection Rehabilitation Protocol

  • Day 1
    1. Full active ROM of joint with muscle going through full lengthening/shortening
    2. Gentle soft tissue mobility
  • Days 2 and 3
    • c. Repeat day 1
    • d. Add stationary bike
    • e. stretching to involved muscles
    • f. Return to running
    • g. Return to sport-specific movements
  • Day 4
    • h. Full return to play

Conclusion

This is the first presentation of chronic hamstring injuries treated with an ultrasound-guided fascial hydrodissection. The procedure is a relatively quick, easy in-office procedure with immediate benefits in both reduction of pain and return to play. In considering cost efficacy, an ultrasound evaluation is more cost-effective than the MRI in the experienced sonographer. The procedural cost of a hamstring fascial hydrodissection also is less expensive than continued physical therapy (21–23).

Further research is warranted in evaluating the efficacy and safety of ultrasound-guided fascial hydrodissection treatments. Larger case series can help to identify average return to play time and complication rate. A larger series also would be important in classifying the most common areas of fascial abnormalities.

The medications injected in this series involved lidocaine, bupivicaine, methylprednisolone, and normal saline. Further research should help to clarify the best medications to inject for the best result and lowest risk of medication-induced side effects.

This case series presented three patients who experienced a prolonged recovery from a chronic hamstring strain, one of the most common injuries in athletes and the general active population. Hamstring strains can range from mild to severe and are a cause of significant missed time and decreased performance in athletes. An ultrasound-guided hamstring fascial hydrodissection is a novel procedure that was effective in this limited series. An expansion of ultrasound evaluation of fascia can improve identification of chronic hamstring strains. Including a fascial hydrodissection as a treatment modality can result in a quicker resolution of symptoms and return to play in addition to decreased health care costs. Further, larger-scale studies should be performed to prove efficacy and safety, as well as to develop protocols that can be easily taught and implemented.

The authors declare no conflict of interest and do not have any financial disclosures.

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