History and Presenting Symptoms The patient, a 24-year-old male semi-professional hockey player, reports a recent right hamstring "4grab" that just docs not seem to be improving. His history includes several injuries to the same hamstring muscle during his collegiate playing career with mixed attempts to stretch and rehab. He also describes varying levels of pain in his lower back and left hip region, which has led him to ask fora complete musculoskelctal evaluation. Exam Findings Vitals. This athletic young male weighs 175 pounds, which at 5" 11"" results in a BMI of 24.4: He is not overweight. He is a non-smoker, docs not drink alcohol, and his blood pressure and pulse rate arc at the lower end of the normal range. Posture and gait. Standing postural evaluation finds relatively good alignment with intact spinal curves but a slightly lower iliac crest on the right along with a lower-right greater trochantcr. His spine appears to be well balanced above with no evidence of lateral curve or list. He also demonstrates right calcancal eversion and a low medial arch (hyperpronation). A tendency to toe out on the right is seen during a standard gait screening, and he confirms his need to be conscious of the positioning of his right foot when skating. Chiropractic evaluation. Motion palpation identifies a mild limitation in left sacroiliac motion with moderate tenderness and loss of endrange mobility. Compensatory fixations arc identified at L4/5 and L2/3. Otherwise, all orthopedic and neurological testing is negative. Primary complaint. Examination of his right lower extremity finds tenderness to palpation at the ischial insertion and in the medial belly of the hamstring muscle group. Straight leg raise is limited to 58° by hamstring tightness and pain, and active knee extension is restricted when the hip is placed in 90° of flexion. Manual muscle testing finds painful weakness in the right hamstring when only moderate resistance is provided. Imaging Because of his history of recurrent strains and the evidence for postural asymmetry, an upright lumbopclvic scries is obtained. The standing AP lumbopclvic view shows a lateral pelvic tilt, a low sacral base on the right, and the right femur head is five millimeters lower. Clinical Impression Hamstring muscle injury associated with chronic biomechani-cal strain. A functional short leg on the right is accompanied by sacroiliac joint motion restriction and compensatory lumbar fixations. Treatment Plan Adjustments. Specific, corrective adjustments for the SI joints and lumbar region were provided as needed. Mobilization and manipulation were performed on his right arch, calcancus. and navicular bone. Support. Individually designed stabilizing orthotics were ordered for his street shoes, and a second pair was fitted into his hockey skates. They were designed to support the arches, decrease calcancal eversion. and reduce the asymmetrical bio-mechanical forces being transmitted to the spine and pelvis. Rehabilitation. He was initially instructed to perform sustained functional hamstring stretches four times a day. After one week, daily strengthening exercises for the right hamstring were progressed from light to strenuous resistance using clastic exercise tubing. Response to Care The spinal and pelvic adjustments were well tolerated, and once he began wearing the stabilizing orthotics. this active hockey player required very few rc-adjustments. His compliance with the recommended exercises was excellent because he was quite motivated to improve his performance and to prevent future hamstring injuries. He was immediately able to wear his or- thotics full time and reported an improved sense of edging and control in his skates. The right hamstring muscle regained full flexibility and balanced strength, and he was released from acute care to a sclf-dircctcd home stretching and sports perfomiance program after a total of eight visits over two months. Discussion While a hamstring muscle "grab" or "pull" is often just a simple strain injury, in some cases there is an underlying biomcclianical fault that makes it recurrent. Careful evaluation of the patient's spine and lower extremities identified the asymmetry in the feet and ankles as a major contributor to his symptoms. Fitting stabilizing orthotics into his skates helped to provide a better boot fit. improved his edge control, and enhanced long-term support for his lower extremities. As with this young man. athletes at all levels appreciate a thorough evaluation and advice that can help to improve sports perfomiance. Dr. John J. Danchik, the seventh inductee to the ACA Sports Hall of Fame, is a clinical professor at Tufts University Medical School and formerly chaired the U.S. Olympic Committee's Chiropractic Selection Program. Dr. Danchik lectures on current trends in sports chiropractic and rehabilitation. He can be reached at docjror■jocs<aaol.com or 617-489-1220.
