D-14F Clinical Case Slide Presentation Muscle Injury
A 39-year-old self-employed painter presented with 1-week of posterior left thigh pain and impaired ambulation after a water-skiing injury. While attempting a dock take-off, he caught a ski, extended his knee and hyperflexed his hip, resulting in immediate severe left buttock pain, exacerbated by sitting. Within 48 hours ecchymoses developed from his buttock down his posteromedial left thigh. Due to persisting ecchymoses, he presented for evaluation at 1 week. By this time his ambulation, pain, and sitting tolerance had improved. He denied any neurologic symptoms. He also had resumed work supervising and assisting with some painting.
Well-appearing jovial male. Gait slightly apprehensive. Ecchymosis extended from the inferior gluteal fold to the popliteal fossa, with associated edema. No observable defect and mid-muscle palpation obscured by edema. Tenderness over the ischial tuberosity with an inability to palpate the proximal hamstring tendons. Hip ROM with knee flexed normal except for ischial tuberosity pain at end-range flexion. Straight-leg raise provoked hamstring pain at 60 degrees on the left vs. 80 degrees on the right. Left hamstring strength 4/5 with the knee flexed at 90 degrees, and 2/5 near full extension. Sensory and distal neurovascular exam normal.
- Severe hamstring muscle strain
- Ischial tuberosity avulsion
- Piriformis muscle strain with hematoma pain inhibiting hamstring function
TESTS AND RESULTS
- Pelvis Radiograph – Normal
- MRI Left LE – complete hamstring avulsion from the ischial tuberosity with 11cm retraction. Large hematoma encompassing sciatic nerve
Complete avulsion of the proximal hamstring muscle
- Pain-free range of motion to prevent contracture
- Isometric strengthening to maintain muscle tone
- Progress to submaximal strengthening for gluteus maximus compensation at the hip and gastrocnemius compensation at the knee
- Neural glide techniques to prevent fibrous adhesions to the sciatic nerve
- Surgical consultation for operative hamstring repair (not pursued by patient due to continued function) FOLLOW-UP Two months after injury, he was climbing ladders and lifting loads at work. Isokinetic strength was 35% of the non-injured hamstring strength.