Editor's note: Dr. Gasparovic has a master's in sports medicine. He is a certified athletic trainer, pain practitioner, strength and conditioning specialist, and an emergency medical technician. He treated rugby athletes at the 1996 Paralympic Games.
Christopher Baldwin is a personal trainer and rehabilitation director at a facility in New Jersey. He is completing a program that will make him eligible to take the National Examination for Athletic Training.
An 18-year-old track athlete entered our facility with chronic left hamstring pain and low back pain. She sustained a hamstring sprain while sprinting for her high school team. After two months of treatment with the school's athletic trainer, the athlete felt little improvement.
We immediately implemented an aggressive rehabilitative program, which included strength training, extreme flexibility training, modalities, and osseous manipulation.
The athlete performed a gait analysis on a treadmill at 2, 5, and 10 miles per hour on a flat surface. At 2 miles per hour the athlete revealed the following findings. External rotation of the bilateral foot with ankle pronation. Valgus stress placed on both knee and a loss of her proper nutation/counter-nutation of the pelvis region. No additional changes were noted at 5 miles per hour.
At 10 miles per hour an increase in all findings were noted with the addition of pain and discomfort within her hamstring and low back region on the left. Visual inspection of the paralumbar musculature revealed an increased prominence of the left paravertebral musculature directly over the site of pain.
Shoe inspection revealed increased wear on the medial posterior heel bilaterally.
Short Leg Syndrome
The leg imbalances examined are due to spastic contraction of the extensor muscles in the lower spine and pelvic girdle. There are many reasons for a short leg (bone deformity, pathology, trauma, joint involvement, or break-down of the arch), our focus will be spastic muscular contraction.
To understand the relevance of a short leg analysis, we will examine a more accurate and descriptive phrase, the contracted leg. This denotes the neuropathological relationship imbalance, which appears as an inneverational overload to the extensor muscles, causing unilateral spastic contraction and unequal extremities. This spasticity occurs when certain muscles are over stimulated. Visualize the function of the central facilitary and inhibitory mechanisms. Normally the facility mechanism increases the normal spinal stretch reflex, while the inhibitory mechanism decreases the reflex. These systems consistently react to proprioceptive input to the cerebral cortex, cerebellum, and brain stem to maintain postural balance.
The cortex stores normal values of body function, while the actual state of the body is monitored and compared to the cortical data by the cerebellum and hypothalamus.
Proprioception is the sensation of joint motion (kinesthesia) and joint position. It is mediated by specialized mechanorecptors which respond to mechanical deformation. These receptors are important in modulating muscle function.
Structural imbalances (fixations or articular joint function) are displayed in the cerebral cerebellar/cortical system as increased input from the ascending cerebellar afferent fibers. The inhibitory influences are prevented from modifying the facilitary influences which now, unopposed, result in innervational overload, exaggerated spinal stretch reflex and a contracted leg.
Evaluation of Low Back and Extremities
The athlete revealed a left short leg and a right convexity of the lumbar spine, motion palpation revealed multiple fixations within the thoracolumbar spine. Myospasm and point tenderness (pt) was noted throughout the paravertebral muscular as well as the involved hamstring. Evaluation of the involved leg and ankle revealed an anterior talus which created a shortening of the posterior compartment musculature of the lower leg, and an anterior tibia which created tension within the hamstring group at its insertion point.
Further evaluation revealed the patient to have a high right hip upon posture analysis. Asymmetrical musculature of the paralumbar region.
Active and passive range of motions of the lumbar spine and hamstring were decreased in all planes by approximately 15 percent with pain noted in flexion in both areas.
The athlete experienced pain within the lumbosacral region when performing a double straight leg raise, a left Lasegue's and bilateral Kemp's.
Excessively tight left internal and external rotator musculature was noted.
All muscle testing were within normal limits (5/5). Pain was noted when the hamstring was tested in flexion.
Radiographs (Lumbar Spine)
There is a mild to moderate deviation of the spinal axis to the right with a convexity, which has created an element of muscle spasm; mild degenerative sclerosis of the apophyseal joints bilaterally; and a low left ischium, due to the sacral deviation and the component of muscle spasm. Loss of the curve with malpositioning is noted. Due to the rotational component, facet syndrome can be expected.
Treatment
Initially interferential with moist heat and deep tissue massage. After three treatments, she complained of an increase in soreness in the hamstring, so contrast therapy was implemented with interferential. Deep tissue work was discontinued and effleurage massage performed.
Phonoporesis in a stretch position with cortisone was utilized about one week into treatment . This treatment proved to be the most effective.
At the end of the session, the athlete was thoroughly stretched in all ranges of motion for the lower and upper body and seen for a chiropractic evaluation and manipulation.
Rehabilitation
Included with treatment was an aggressive rehabilitation program consisting of Cybex, sitting and laying leg curl, and slant board exercise. We utilized split routines alternating between cardio work and weight training.
The principle of specific adaptation to imposed demands was utilized with minimal rest periods. The lower muscle groups were our main focus.
Strengthening and Conditioning
A comprehensive strengthening and condition program was implemented which included: aggressive flexibility utilizing proprioceptive neuromuscular facilitation stretching (PNF); conditioning was implemented utilizing the Versa Climber; upper body ergonomics (UBE); running with bands, and plyometrics.
Due to the athlete's injury, which occurred during the season, it was imperative to keep her well conditioned for her sport. Utilization of the Versa Climber simulating full out sprints, placed little stress on the hamstring and proved to be effective. Weight training utilizing Cybex, performing open and closed chain kinetic exercises with moderate to high repetitions.
Conclusion/Prognosis
The athlete showed great improvement in strength and flexibility after two weeks of treatment and rehabilitation. Osseous manipulation to the lumbar, pelvis, and extremity helped the hamstring to have an improved biomechanical advantage leading to her recovery. The athlete met the long and short-term goals that were set for her and is now engaged in normal sprint workouts. The mechanical dysfunction is now monitored once every 1-2 months.
Frank Gasparovic, DC, MS
Christopher Baldwin, BS, personal trainer
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