The history is of a 12-year-old female gymnast presented with a 4-week history of a painful right posterior thigh.
The pain started on the run-up to a vault, towards the end of a 2-hour training session. The patient did not describe immediate pain but rather, once aggravated, she suffered a fairly rapid onset of a deep ache and sharp pain that was made worse the more running/jumping she did.
Her symptoms eased after a few days of rest and she, therefore, returned to her sport, only for the same symptoms to recur. On further questioning, the patient described a few months of struggle with speed and propulsion in her run-ups.
This patient had increased the intensity, duration and frequency of her training over the preceding weeks due to an impending competition. She trained in excess of 12+ hours per week on top of school sport. Mum reported a recent growth spurt.
The objective assessment.
The patient was very tall, but at rest, in standing, she was unable to fully weight-bear over the right side.
The lower back range of motion was good but reproduced pain at the back of the right leg on bending forwards.
Hip range of motion and strength was good.
The pain was reproduced on resisted right knee flexion at 90 degrees and on palpation over the hamstring towards the buttock crease.
There was no specific pain over the ‘sit-bone’ (Ischial Tuberosity) but slightly below. Active straight leg raise on the right was limited to 60 degrees on the right by pain and restriction compared to over 100 degrees on the left.
Activation of the gluteals and hamstrings in shoulder bridge also reproduced her pain.
There was a weakness also found in the deep core muscles – transverse abdominus.
Diagnosis -Non-insertional Hamstring tendinopathy
Initial treatment was complete rest for nearly 2 weeks, using ice and compression and analgesia where necessary. No school sports.
Once the patient was able to walk and carry out normal functional activities such as stairs, getting in and out of bed etc pain-free rehab was progressed.
Treatment Goals – see ref 1 and 2.
Length – hamstrings, hip flexors, gastric complex
Strength – hamstrings, gluts in non-weight-bear initially progressing intensity and repetition as pain allowed.
Gait re-education – equal weight-bear, stride length, pace etc
Core stability – maintain spinal neutral in all functional postures
Graduated return to running
In liaison with her Coach – a gradual return to more sports specific and dynamic movements in at her gymnastics club after another 4 weeks.
This whole process took up to 6 months. We found underlying weakness issue with her deep core muscles and specific tightness in the lower limbs.
She now works hard with core stability, gluts strength and stretches more regularly after each gymnastic session to prevent injury recurrence.