Background – Hamstring pain
This case study presents a young adult with hamstring pain that does not respond to treatment. It challenges clinical reasoning regarding an evolving diagnosis and evaluation of treatment outcomes as well as forward planning.
Minimum level
Physiotherapist with 1+ years experience
History
Michael is a 32 year old Physiotherapist who has experienced 4 months of worsening hamstring pain.
The pain initially presented without incident or any new activities, although Michael had increased his volume of cycling due to reduced work hours around this time.
The hamstring pain is aggravated after performing an increased amount of manual techniques at work (particularly lumbar spine mobilisations) and after more intense cycling sessions. There is no noticeable increase in pain during the activity.
What follow up questions would you ask Michael regarding these activities?
The hamstring pain presented like a low grade muscle strain so he commenced a hamstring rehab program including hamstring curls, deadlifts and hamstring bridges.
Discuss the appropriateness of the hamstring exercises for Michael’s injury given the uncertain diagnosis.
The hamstring pain seemed to ease after a few weeks but then returned to the pre-rehab level of pain 4 weeks later.
Suggest possible reasons behind the initial improvement in symptoms with hamstring rehab work in light of the lack of ongoing improvement.
Michael switched approaches to neural structures, adding neural glides to his program. After one week without change, he dropped the hamstring strength work and just performed the neural glides daily.
The neural approach did not alter his symptoms and the hamstring pain has remained at the same intensity and location for the past two months.
How does this information affect your diagnostic reasoning?
He does not notice any abnormal back pain aside from his usual post-work lumbar spine ache, which has been consistent since he commenced work as a Physiotherapist.
What follow up questions would you ask Michael regarding his back pain?
The hamstring pain does not extend beyond the hamstring muscle belly and there are no referred symptoms past his knee.
Explain how this information affects your reasoning of potential lumbar nerve root compromise.
He has no paraesthesia, tingling or numbness.
Does the absence of neuro symptoms exclude any particular pathologies?
There are no symptoms in his other leg.
His red flag screening questions are all clear.
How effective are red flag screening questions in excluding sinister pathology?
Imaging
An ultrasound of his hamstring was reported as normal and included his hamstring muscle belly and proximal and distal tendons.
Comment on the accuracy of ultrasound and which hamstring injuries may be missed on ultrasound.
An X-ray and subsequent MRI of his lumbar spine showed loss of disc height, disc degeneration and small central disc bulges at L4-5 and L5-S1 without involvement of the adjacent nerve root.
(For further reading and context, see these papers on normal MRI findings and findings in asymptomatic patients – the 2nd paper is the reference for the adjacent table).
Do you think the finding of disc degeneration is relevant to the current presentation?
Are there any conditions that you can exclude based on Michael’s MRI?
Objective assessment
Michael is a healthy build with a BMI of 24.
If Michael had a BMI over 30 (obese), would this information alter your diagnostic reasoning?
His lumbar range appears normal and symmetrical and does not provoke any symptoms.
Does that finding match your expectation?
Explain why it does/does not match your expectation.
Hip range is normal, symmetrical and pain-free and all provocation tests at the hip are negative.
Hamstring range in a 90/90 test is 25 degrees of knee flexion bilaterally and does not provoke symptoms.
Does this alter your diagnostic reasoning?
SLR is 70 degrees and negative on both legs. Slump test is uncomfortable in his lumbar spine but does not provoke the hamstring pain.
Explain how you’re interpreting this finding and if it contributes to your diagnostic reasoning.
Hamstring muscle isometric muscle tests are tested in short and long positions and are all negative for pain or weakness.
What further testing would you perform at this stage?
Neurological testing (sensation, muscle power, reflexes) are all negative.
Does a negative neuro exam exclude nerve root compromise?
What further testing would you have performed at this stage?
Management planning
Would you consider a referral to a Neurosurgeon in Michael’s case? Justify your answer.
And what might trigger a referral at a later stage?
What is your initial plan for treatment?
What outcome would you expect as the first sign of a positive response to treatment?
Would you suggest any modifications to Michael’s aggravating activities? Justify your answer.
If the initial treatment plan is not providing any relief, what would be your next step?
Are there any imaging options that you would consider if treatment is unsuccessful?