I recently travelled to the Australian National Touch-Football Titles as the physiotherapist for a number of teams. (For the uninitiated, touch is a form of rugby without the body contact or the goalposts.) Whilst there, I handled two injuries that form an interesting case study highlighting some key points for any sports therapist dealing with posterior thigh pain.
The open mixed team had just finished their first game of the carnival. I was promptly visited by two team members, both claiming to have just strained their hamstrings. Both were in quite a panic, already imagining themselves confined to the benches for the rest of the tournament.
And here’s my first key point: no matter how many athletes you are in charge of at a big event, or how short of time, never believe an athlete’s self-diagnosis. Listen, but make your own assessment.
Danno and Johnno (everyone has nicknames in footy teams, so these will serve for our purposes) were both 30 years old. Both, the coach told me, were very important to the team – which was playing its second game later that day.
Danno reported sprinting from dummy half after scooping the ball off the ground when he pulled up with a twinge of pain in his posterior thigh. He had a history of hamstring strains over the years while playing touch football, but the only detail he could remember was that last year he’d had a minor strain that he rested for two weeks.
After some probing from me, he revealed that his lower back was quite uncomfortable when he sat for long periods and he always woke up stiff the morning after a footie game. This had not been particularly bad lately. He had no pain elsewhere in the leg, just in the mid-hamstring belly, slightly to the medial side. Nor did he have any pins and needles or numbness. Danno now walked with a limp.
Stretching the muscle reproduced his symptoms, as did concentric and eccentric muscle contractions. The medial hamstring muscle belly was very tender to palpation. His lumbar spine flexion was limited by pain in the hamstring and ‘slump’ testing (for neural tension) reproduced just a normal tightness sensation behind the knee that limited his range of movement, the same as the other side. He did not reveal any remarkable tenderness through his gluteal muscles or lumbar spine, but he was very stiff through his lowest two lumbar spine segments.
No one, it seems, escapes the team’s bonding rituals. The player deemed to have made the most stupid remark on any given day is obliged to wear a wig and dress throughout the next day, except when playing. So Johnno presented to the plinth looking fetchingly female.
When I asked what had happened, Johnno told me that ‘I just started getting tight and felt really restricted in my hamstring.’ Any twinges when he sprinted or scooped the ball? ‘No, it just kept getting tighter and tighter, so I came off.’
That is probably the most important information from the assessment. If an athlete has sprained a hamstring, they will usually feel a sudden sharp pain during explosive movement. But there is a case in which an athlete with a chronic recurring hamstring strain has felt a sensation of just tightening when in fact there is minor straining of scar tissue. Further assessment will reveal if this is relevant to Johnno’s case.
Johnno has had similar ongoing lumbar spine problems to Danno, but they had been particularly bad over the past month or two. With further questioning he revealed that during pre-tournament training, he had been getting unusual cramping sensations in his calf on the same side as his hamstring problem and regularly had to stop and stretch – which didn’t seem to have any effect.
Johnno’s hamstring pain was in a similar area to Danno’s, but he could not isolate it. Even when resting he had a vague low-grade aching sensation. He had no pins and needles or numbness, nor any specific lumbar spine pain, apart from a slight ache across the base of his back that was quite normal for him after playing touch. Johnno did not walk with a limp.
His lumbar spine flexion was limited by tightness in his hamstring and behind the knee and his lumbar extension at the end of range produced a catch of pain on the same side as his hamstring problem.
Slump testing reproduced symptoms that were eased by release of cervical flexion. Muscle contractions, both concentric and eccentric, and passive stretching produced slight discomfort in his hamstring but no pain, as did stretching. His range of movement on the affected side was decreased by 10 degrees in the straight leg-raise position compared to his good side. On palpation, Johnno was tender in both his hamstring and calf but not acutely painful at any point in the muscle like Danno. His lumbar spine, gluteal muscles and piriformis demonstrated significant muscle spasm and he was very tender to palpation at L5 centrally and L5/S1 on the affected side.
It should now be obvious to whom I had to break the bad news. I told Danno and the coach that he would struggle to take part in the rest of the carnival. Danno had sustained a bad grade I strain of his hamstring that would keep him out of action for at least two weeks.
I suspected also that his hamstring problems over the years were closely related to his lumbar spine stiffness. Often lumbar spine stiffness and increased neural tension create tightness and spasm within the hamstring muscles. This predisposes athletes to hamstring strains, and the likelihood increases with age.
Danno wanted to try and play on the final day, even if he wasn’t at full strength. He understood there was a strong chance that he would worsen his hamstring strain. I started him on 24 hours of rest, elevation, compression and icing, after which we did gentle stretching, soft tissue work and a daily progressive running programme, designed to accelerate the rehab.
Johnno was surprised to hear that with the right approach he should be able to get through the tournament. I suspected that Johnno had a minor underlying chronic disc problem in his lumbar spine and was suffering from referred pain in his hamstring as a result of the disc irritating neuro-meningeal structures.
I began Johnno’s treatment immediately, concentrating on releasing local trigger points and muscle tension through the hamstring muscle belly and calf. This was important to reduce the chance of a subsequent strain. It would also make him feel much freer. I then started on joint mobilisations through his lumbar spine as well as soft tissue work through his erector spinae, quadratus lum-borum, gluteals and piriformis. This treatment was continued daily.
I designed a stretching programme that concentrated on the above areas and neural mobilisations with a towel in the straight leg raise position. This was to be done before and after every match and again at night, back at the hotel.
I talked with the coach about using Johnno on the field only when necessary, particularly for that afternoon’s match and the next day.
The tournament turned out as expected. Danno battled on with his rehab and played only in the semi-final, directing the ball and setting up plays, but only ever reaching about 75% of top speed. Johnno on the other hand played unrestricted through the rest of the tournament. He didn’t suffer any pain or tightness in the hamstring or calf and showed many opponents a clean set of heels.
When assessing any posterior thigh pain you should keep the following differential diagnoses in mind:
Never rule out the possibility of more than one of these diagnosis being responsible for the symptoms. For example, you may very well get a patient with a sacro-iliac joint dysfunction and a chronic hamstring tendinopathy or an athlete who has just had a grade I hamstring strain but also has a lot of pain referred from neuro-meningeal structures.
Posterior thigh pain is complex. There are many and often multiple origins. The key to managing this pain effectively is accurate assessment. You should always keep your differential diagnoses in the back of your mind and methodically discount each one as you go. You can often make instant improvements with referred pain, and patients will understandably be very happy – as Johnno was. For this reason, always fully assess, even when under pressure.
And for the record, the team lost in a close semi-final game to the eventual tournament winners.