1. Ν.G.Malliaropoulos contact@sportsmed.gr MD, Msc & Dipl in SEM, PhD, ECOSEP, FFSEM(UK) Consutant Sports &Exercise Physician Barts and The London Senior Lecturer QMUL CSEM Fellow Faculty Sports and Exercise Medicine (UK) Director of the Athletics National Sports Medicine Centre Thessaloniki, Greece

2. Muscle injuries are among the 1.most common 2.most misunderstood, and 3.inadequately treated conditions in sports medicine. According to some studies, muscle injuries account for 10 - 30% of all injuries in sport. Muscle injuries often occur during sport or training with over 90% caused more often by indirect trauma (overloading) OR by direct trauma (impact). Muscle injuries

3. September 14 th 2015 George Malliaropoulos

4. Hamstring Injuries Definition Acute Non Contact Posterior Thigh Muscle injuries, with all the athletes reporting an incidence during training or competition,either structural or functional, presented with the Musculoskeletal triad, leading to a time loss more than a day. Fuller C et al.Consensus statement on injury definitions and data collection procedures in studies of football (soccer) injuries.Scand J Med Sci Sports. 2006;16:83-92. Malliaropoulos NG. Non contact Hamstring injuries in sports. Muscles Ligaments Tendons J. 2013 Jan 21;2(4):309-11Non contact Hamstring injuries in sports. Malliaropoulos N,et al Posterior thigh muscle injuries in elite track and field athletes.. Am J Sports Med. 2010 Sep;38(9):1813-9.Posterior thigh muscle injuries in elite track and field athletes. Askling CM, Malliaropoulos N, et al.High-speed running type or stretching-type of hamstring injuries makes a difference to treatment and prognosis. Br J Sports Med. 2012 Feb;46(2):86-7.High-speed running type or stretching-type of hamstring injuries makes a difference to treatment and prognosis. Mueller-Wohlfahrt HW et al, Terminology and classification of muscle injuries in sport: the Munich consensus statement.Br J Sports Med. 2013 Apr;47(6):342-50.Terminology and classification of muscle injuries in sport: the Munich consensus statement. J Ekstrand, et al, Injury incidence and injury patterns in professional football: the UEFA injury study. Br J Sports Med 2011;45:553–558

5. Lower Limb Epidimiological Data Track&Field 1990-2011 Overuse injuries Hamstring Injuries Ankle Ligament Injuries Knee Injuries Quatro Muscle Injuries PTM strains were the most common injury occurrence (16%), according with surveillance study of the 2007 International Association of Athletic Federations (IAAF) (2008) Literature has emphasised HAM high clinical relevance in professional athletes.

6. HAMSTRING IS IT A CLINICAL PROBLEM ??? Epidemiologically muscle injuries have been increasing over the last 12 years despite assessing risk factors and applying prevention protocols Classifying & Grading the severity of the NCHI does it matters?

7. There are at least TWO distinctly different types of acute NON Conatct hamstring pathology The most common injury type occurs during high-speed running and the other occurs during movements leading to extensive lengthening of the hamstrings, such as; high kicking, sliding tackle and sagittal split.  High-speed running type is mainly located to the long head of biceps femoris and typically involves the proximal muscle-tendon junction.  Stretching-type is located close to the ischial tuberosity and typically involves tendon tissue of the semimembranosus.  A general rule of thumb is, ‘the closer to the ischial tuberosity, the longer the rehabilitation period’. High-speed running type or stretching-type of hamstring injuries makes a difference to treatment and prognosis. Carl M Askling, Nikolaos Malliaropoulos, Jon Karlsson Br J Sports Med February 2012 Vol 46 No 2 Mechanism Hamstring tears have personalities!

8. grade 0 a normal US grade 1 subtle US findings ill-defined hyperechoic or hypoechoic intramuscular areas or a swollen aponeurosis grade 2 partial muscle tears Haematoma formation grade 3 complete muscle tears Haematoma formation Longitudinal study comparing sonographic and MRI assessment of acute and healing hamstring injuries. Connell DA, Schneider-Kolsky ME, Hoving JL, et al. AJR Am J Roentgenol. 2004;183:975-984. Value of Sonography Combined With Clinical Assessment to Evaluate Muscle Injury Severity in Athletes Yannick Guillodo, MD; Ronan Bouttier, MD; Alain Saraux, MD, PhD Department of Rheumatology, Cavale Blanche Teaching Hospital, Brest Cedex, France Journal of Athletic Training 2011:46(5):500–504 Longitudinal study comparing sonographic and MRI assessment of acute and healing hamstring injuries. Connell DA, Schneider-Kolsky ME, Hoving JL, et al. Am J Roentgenol. 2004;183:975-984. Peetrons P. Ultrasound of muscles. Eur. Radiol. 2002;12(1):35-43. By Imaging 2a

9. Classifying & Grading the severity of the NCHI does it matters? By Imaging 2b The first MR study that described findings with poor prognosis of muscle injury evaluated 14 patients and found that muscle rupture and retraction, haemorrhage, ganglion-like fluid collections, and greater than 50% cross-sectional involvement were associated with convalescent periods of more than 6 weeks Follow up during rehabilitation time ????

10. Acute muscle strain injuries: a proposed new classification system Otto Chan, Angelo Del Buono, Thomas M. Best, Nicola Maffulli Knee Surg Sports Traumatol Arthrosc 2012 Location (Anatomical &Imaging ) describes an imaging (magnetic resonance or ultrasound), which considers the anatomical site, pattern and severity of the lesion in the acute stage MRI negative injuries

11. Location (Anatomical &Imaging) focused 5 Grades in Total  Classification based on extent (grades 0–4) and site (a, b or c) of injury  Site of injury is determined as myofascial (a), muscular/musculotendinous (b) or intratendinous (c).  Extent of injury is determined by MRI features of the muscle injury. 2014

12. M(Mechanism)L(Location) G(Grade)R (Re-injury) 2015

13. Askling has argued MRI diagnosis is helpful for distinguishing the two types of hamstring tears. Jan Ekstrand et all,2012 of 23 European professional team to include the largest study characterising the severity of hamstring strain using MRI. Remarkably, 70% of hamstring injuries seen in professional football showed no signs of fibre disruption on MRI.!!!!! Still, these injuries which occurred without imaging alterations caused the majority of days missed due to injury. !!!!!! Hamstring muscle injuries in professional football: the correlation of MRI findings with return to play. Jan Ekstrand, Jeremiah C Healy, Markus Waldén, Justin C Lee Bryan English, Martin Hägglund.Br J Sports Med 2012;46:112–117. Does MRI helps ??

14. CLINICAL 3A Time to walk pain-free > 24 h after a hamstring injury. previous hamstring injury are predictors of time to return to competition and recurrence (4 weeks to RTP for the time to walk ) Clinical predictors of time to return competition and of recurrence following hamstring strain in elite Australian footballers Price Warren, et al. Br J Sports Med 2010 44: 415-419 According to the UEFA consensus discussions, injury severity must be categorized as minimal (1-3 days absence), mild (4-7 days), moderate (8-28 days) and severe (> 28 days.) ‘it is therefore crucial to establish valid criteria to recognise severity and avoid premature return to full activity and the risk of reinjury’. POSTERIOR THIGH MUSCLE INJURIES IN ELITE TRACK AND FIELDATHLETES: A NOVEL CLINICAL CLASSIFICATION. N Malliaropoulos, Nicola Maffulli,et all. ΑJSM 2010

15. Classification based on: 1. Location(HAM) –Mechanism(Non Contact) 2. Clinical examination & re evaluation 48 hours post injury 3. Active range of motion (goniometry) 4. Ultrasonographically findings 5. Recorded time to full rehabilitation. Hamstring injuries: Malliaropoulos Thesis,QMUL,MSc 1999. Classifying and Grading NCHI does it matters?- Clinical 3B POSTERIOR THIGH MUSCLE INJURIES IN ELITE TRACK AND FIELDATHLETES: A NOVEL CLINICAL CLASSIFICATION. N Malliaropoulos,et all Am J Sports Med. 2010 Sep;38(9):1813-9

16. Musculoskeletal Injury Triad 1.Tenderness to palpation 2.Pain with resisted movement (Knee flexion, extension of the hip) 3.Pain with passive stretching flexion of the hip with the knee extended. Clinical evaluation at 48 hours All athletes were re-evaluated 48 hours after the initial injury, this included the following: Palpation of the posterior aspect of the thigh with the athlete prone to elicit tenderness if present Provocation of pain on isometric contraction of the posterior thigh muscles Provocation of pain on passive hip flexion with the athlete supine

17. A-ROM both sides POSTERIOR THIGH MUSCLE INJURIES IN ELITE TRACK AND FIELDATHLETES: A NOVEL CLINICAL CLASSIFICATION N Malliaropoulos MD,Μsc-SEM, PhD. E.Papacostas MD,Orth. O. Kiritsi MD, A. PapaladaPT, N. Gougoulias MD,Orth,PhD, Nicola Maffulli MD, PhD, FRCS(Orth) American Journal of Sports Medicine 2010

18. 1 st degree injuries are Functional injuries ???? Total ham ruptures are not common in Elite athletes Clinical Grade AROM deficit FRT Percentage (%) IamgingTreatment 1 ST <10 ο degrees 6.9 (2.0) 6.9 (2.0) 45.4 45.4Rehab 2 ND 10 ο – 19 ο degrees 11.7 (2.4) 35.2 35.2U/S Laser-PRP -Rehab 3D3D3D3D 20 ο - 29 ο degrees 25.4 (6.2) 15.8 15.8MRI Non Weight Bearing Laser - PRP 4 TH >30 ο degrees 55.0 (13.5) 3.6MRIOperation?? PROPER TREATMENT PROPER TREATMENT Clinical value PROPER REHABILITATION PROGRAM PROPER REHABILITATION PROGRAM Clinical value ESTIMATION OF RETURN – TO – SPORTS TIME ESTIMATION OF RETURN – TO – SPORTS TIME Clinical Prognostic value REDUCTION OF RECCURENCE REDUCTION OF RECCURENCE Clinical Prognostic value

19. Clinical relevance: ‘bye, bye MRI’? In clinical practice, the diagnostic work up generally consists of history, physical examination and, possibly, additional imaging. Recent data clearly show that MRI did not provide additional prognostic information Moen MH, et al Predicting return to play after hamstring injuries. Br J Sports Med 2014;48:1358–63. Statistics on the table There are many different factors determining RTP in hamstring injuries, and anatomical severity, as measured by the MRI, is only one of the factors. But the current available data show that MRI does not substantially contribute to the answer of the athletes’ most important and simple question after they are injured: ‘When can I return to play?’

20. Functional Assessment Scale for Acute Hamstring Injuries a condition-specific patient-reported outcome measure to measure symptoms and their effect on function and sports ability

24. History Clinical examination D.D Follow up Re evaluation Re evaluation A R O M A R O M IMAGING IMAGING DEGREE OF SEVERITY FASH Treatment Treatment REHABILITATION REHABILITATION RTP RTP FASH FASH 48h POLICE Early Clinical Assessment

25. Thank you for your attention!!!