Hamstring Injuries in the Athlete: Diagnosis, Treatment, and Return to Play.

Hamstring injuries are very common in athletes. Acute hamstring strains can occur with high-speed running or with excessive hamstring lengthening. Athletes with proximal hamstring tendinopathy often do not report a specific inciting event; instead, they develop the pathology from chronic overuse. A thorough history and physical examination is important to determine the appropriate diagnosis and rule out other causes of posterior thigh pain. Conservative management of hamstring strains involves a rehabilitation protocol that gradually increases intensity and range of motion, and progresses to sport-specific and neuromuscular control exercises. Eccentric strengthening exercises are used for management of proximal hamstring tendinopathy. Studies investigating corticosteroid and platelet-rich plasma injections have mixed results. Magnetic resonance imaging and ultrasound are effective for identification of hamstring strains and tendinopathy but have not demonstrated correlation with return to play. The article focuses on diagnosis, treatment, and return-to-play considerations for acute hamstring strains and proximal hamstring tendinopathy in the athlete.

Simulation-Based Education for Urgent Medical Complications Common to the Rehabilitation Setting: An Educational Program for Physical Medicine and Rehabilitation Residents.

BACKGROUND: Simulation technology is being increasingly adopted into medical education and is consistently associated with positive effects on knowledge, skills, and patient-related outcomes. There is little evidence on the use of simulation technology for the instruction of urgent medical complications to physical medicine and rehabilitation (PM&R) residents. OBJECTIVE: To examine whether a simulation-based educational program can improve PM&R resident confidence and knowledge in the assessment and management of urgent medical complications. DESIGN: Pretest-posttest design. SETTING: Academic freestanding acute inpatient rehabilitation hospital. PARTICIPANTS: Twelve Post-Graduate Year (PGY)-2 PM&R residents at the start of the academic year. METHODS: Residents completed an integrated didactic and simulation-based curriculum on the assessment and management of five urgent medical complications: seizures, agitation, ventricular assist device (VAD)-associated complications, sympathetic storming, and autonomic dysreflexia. Simulations were conducted using a high-fidelity manikin. MAIN OUTCOME MEASUREMENTS: Surveys and knowledge assessments were completed at baseline and immediately following training. Survey responses were recorded on a Likert scale ranging from 1 = strongly disagree to 5 = strongly agree. Multiple-choice knowledge assessments were scored out of 100%. Within-group differences from baseline to postintervention were analyzed. RESULTS: There was a positive correlation between baseline experience and baseline confidence scores (r = 0.877). Improved confidence was demonstrated in the assessment and management of all five topics (P < .05). Knowledge assessment scores significantly improved from 57.8% (95% confidence interval [CI] 50.6% to 65.4%) at baseline to 85.0% (95% CI 81.6% to 88.4%) following the course (P < .001). The education program was rated highly by both learners (mean satisfaction score, Likert score [LS] = 4.6) and instructors (mean satisfaction score, LS = 4.5). CONCLUSIONS: Application of a simulation-based educational model to the instruction of urgent medical complications to PM&R residents resulted in increased knowledge with added benefits of confidence building and high levels of enjoyment. LEVEL OF EVIDENCE: II.

Preserving the Shoulder Function of an Elite Paratriathlete.

Shoulder pain in wheelchair users that participate in competitive adaptive sports can be a troublesome condition. Shoulder pain not only affects athletic performance but also affects functional activities such as wheelchair propulsion and weight bearing during transfers. Managing pain in these athletes thus presents a unique challenge because of the difficulty in achieving relative rest and the need to modify athletic shoulder-focused rehabilitation strategies. In all athletes, it is vital to establish an early, accurate diagnosis and optimize conservative treatment before considering surgical interventions to avoid excessive shoulder-related morbidity, loss of function, and, worse, loss of independence.

Resident Accuracy of Electromyography Needle Electrode Placement Using Ultrasound Verification.

BACKGROUND: Electromyography (EMG) and musculoskeletal (MSK) ultrasound (US) are core learning objectives during physical medicine and rehabilitation (PM&R) training. However, there have been no prior studies using MSK US to assess the acquisition of EMG procedural skills during residency training. This study aims to demonstrate the differences in skillful needle placement between junior and senior physiatry residents. The integration of both EMG and MSK US may have tremendous potential for additional learning opportunities related to electrodiagnostic education. OBJECTIVE: To determine the accuracy of anatomic landmark-guided EMG needle electrode placement in commonly used muscles by PM&R resident physicians. DESIGN: Cross-sectional study. SETTING: An academic PM&R residency program. PARTICIPANTS: Twelve (5 postgraduate year [PGY] -3 and 7 PGY-4) PM&R resident physicians participating in a MSK US training course. METHODS: Twelve PM&R residents in the eighth month of their third and fourth years of postgraduate training performed anatomic landmark-guided needle placement to the extensor indicis proprius (EIP), pronator teres (PT), peroneus longus (PL), and soleus muscles of live subjects. Once the needle electrode was satisfactorily placed, needle localization was verified with US. MAIN OUTCOME MEASURES: Accuracy of EMG needle electrode placement. RESULTS: The overall accuracy of needle electrode placement for all resident participants was 68.8%. The mean accuracy of the 4 selected muscles was 50% by PGY-3 residents and 82.1% for PGY-4 residents (P = .01). EIP was the most commonly missed muscle, with correct placement performed by 20% of PGY-3 and 42.9% of PGY-4 residents. PGY-3 residents demonstrated 60% accuracy with localizing the PT, PL, and soleus muscles. PGY-4 residents demonstrated 85.7% accuracy for PT, and 100% accuracy for both PL and soleus muscles. CONCLUSIONS: Senior residents demonstrated greater accuracy of landmark-guided needle placement than junior residents. EMG procedural skills are important milestones in PM&R training, and MSK US may be a useful tool to enhance resident learning.

Conservative Treatment of Subacute Proximal Hamstring Tendinopathy Using Eccentric Exercises Performed With a Treadmill: A Case Report.

STUDY DESIGN: Case report. BACKGROUND: Proximal hamstring tendinopathy in runners is characterized by pain with passive hip flexion with the knee extended, active hip extension, and pain with sitting. Relatively little literature exists on the condition, and publications on nonsurgical treatment protocols are even more scarce. Surgical intervention, which comprises the majority of literature for treatment of this condition, is an option for cases that fail to respond to nonsurgical treatment. CASE DESCRIPTION: The patient was a 34-year-old, otherwise healthy male triathlete with unilateral proximal hamstring tendinopathy diagnosed by ultrasound, who had pain only with running and prolonged sitting. After he failed to respond to 4 weeks of eccentric knee flexion and lumbopelvic musculature strengthening exercises, an eccentric hip extensor strengthening program using a treadmill was initiated. This treadmill exercise was performed on a daily basis, in addition to a lumbopelvic musculature strengthening program. OUTCOMES: The patient noted a decrease in pain within 2 weeks of initiating the new exercise, and was able to return to gradual running after 4 weeks and to speed training after 12 weeks. He returned to competition shortly thereafter and had no recurrence for 12 months after the initiation of therapy. His score on the Victorian Institute of Sport Assessment-proximal hamstring tendons improved from 23 on initial presentation to 83 at 12 weeks after the initiation of therapy. DISCUSSION: We described the management of a triathlete with subacute proximal hamstring tendinopathy, who responded well to nonsurgical treatment using eccentric hip extension strengthening using a treadmill. LEVEL OF EVIDENCE: Therapy, level 4.

Resident accuracy of joint line palpation using ultrasound verification.

OBJECTIVE: To determine the accuracy of knee and acromioclavicular (AC) joint line palpation in Physical Medicine and Rehabilitation (PM&R) residents using ultrasound (US) verification. DESIGN: Cohort study. SETTING: PM&R residency program at an academic institution. PARTICIPANTS: Twenty-four PM&R residents participating in a musculoskeletal US course (7 PGY-2, 8 PGY-3, and 9 PGY4 residents). METHODS: Twenty-four PM&R residents participating in an US course were asked to palpate the AC joint and lateral joint line of the knee in a female and male model before the start of the course. Once the presumed joint line was localized, the residents were asked to tape an 18-gauge, 1.5-inch, blunt-tip needle parallel to the joint line on the overlying skin. The accuracy of needle placement over the joint line was verified using US. MAIN OUTCOME MEASURES: US verification of correct needle placement over the joint line. RESULTS: Overall AC joint palpation accuracy was 16.7%, and knee lateral joint line palpation accuracy was 58.3%. Based on the resident level of education, using a value of P < .05, there were no statistically significant differences in the accuracy of joint line palpation. CONCLUSIONS: Residents in this study demonstrate poor accuracy of AC joint and lateral knee joint line identification by palpation, using US as the criterion standard for verification. There were no statistically significant differences in the accuracy rates of joint line palpation based on resident level of education. US may be a useful tool to use to advance the current methods of teaching the physical examination in medical education.

The efficacy of lumbar epidural steroid injections: transforaminal, interlaminar, and caudal approaches.

Conservative management of low back pain includes the use of lumbar epidural steroid injections, which have become increasingly more popular in the last 20 years. The body of literature regarding the efficacy of these injections is vast, conflicting, and difficult to summarize. This article reviews the updated evidence for efficacy and the indications for these injections.

Efficacy of lumbosacral transforaminal epidural steroid injections: a systematic review.

OBJECTIVE: To critically review the best available studies evaluating the efficacy of lumbosacral transforaminal epidural steroid injections (TFESIs) in the treatment of radicular pain. DATA SOURCES: MEDLINE, EMBASE, and the Cochrane database were searched for the period between 1950 and May 2008. Search terms included epidural steroid injection (ESI), transforaminal ESI, foraminal ESI, selective nerve root block, nerve root injection (NRI), selective NRI, periradicular infiltration, and periradicular injection. Randomized controlled trials (RCTs), published in English, which evaluated the efficacy of fluoroscopically guided TFESIs were reviewed. STUDY SELECTION: Studies were analyzed with a quality checklist modeled after the 2001 CONSORT Statement: Revised Recommendations for Improving the Quality of Reports of Parallel-Group Randomized Trials. Nine studies were found to include a majority of these items. DATA EXTRACTION: Data included study design, inclusion criteria, symptom duration, randomization protocol, blinding protocol, intervention, control, outcomes, follow-up, dropout, statistical analysis, and conclusions. DATA SYNTHESIS: Each article was assigned a level of evidence: I (high-quality RCT) or II (RCT with <80% follow-up, no blinding or improper randomization). Studies were divided according to control, and overall evidence was graded as A (good), B (fair), C (conflicting/poor quality), or I (insufficient). CONCLUSIONS: There is fair evidence supporting TFESIs as superior to placebo for treating radicular symptoms. There is good evidence that TFESIs should be used as a surgery-sparing intervention, and that TFESIs are superior to interlaminar ESIs (ILESIs) and caudal ESIs for radicular pain. In patients with subacute or chronic radicular symptoms, there is good evidence that a single TFESI has similar efficacy as a single transforaminal injection of bupivacaine or saline. Future studies should address the ideal number of injections. While more placebo-controlled trials are needed to conclusively define the role of TFESIs, current studies support their use in the treatment of lumbosacral radicular pain.