A 24-year-old male with posterior aspect of knee pain for 12/12; active runner and football

player. Pain started with running, continued to play football with Sx. exaggerated the
pain. No H/O fall or injury. Full ROM in knee, no pain in any other activity. Expectation
of the patient is to return to running.
By Reshma Jaya Prakash
MSK Physiotherapist

Before case study, consent gained from the patient for case discussion.

CASE REPORT

SUBJECTIVE

C/C Patient complained about posterior aspect of left knee pain for 1 year, recently
exaggerated 6/12 before. No pain at rest, pain only experience while speed walking,
walking longer distance and running. Recently 3 months before, started playing football
again with Sx and pain exaggerated. He is an active sprint runner ever since the age of 12.
Hence his expectation is to return to athletes as soon as possible. Recently he has been
experiencing radiating pain to L gluteal also. He described his pain as sharp triggered
more during acceleration and not allowing him to complete full stride length. There is no
giving away/ popping/ cracking sound. This pain hasn’t stopped him from running but the
endurance and distance covered reduced.

Assessment is based on NICE 2020 guidelines: Kristin, 2010.

H/O: No H/O fall, previous injury. No physical abuse

or domestic violence.
No swelling/ redness on the initial onset.
No H/O corticosteroid injection, surgery
No previous rehabilitation for the same problem.

PAIN
Onset of pain was sudden after the run.
Type of pain: sharp intermittent (every day at least
once) and constant aching.
Pain is more evening comparing to daytime.
Radiating pain present in L gluteal muscle.

Pain in other joints: nil

No P & N or numbness
Site of maximal pain the L hamstring insertion.
No swelling/ bruising
Weight bearing in standing VAS 3/10
Stair climbing VAS 5/10
Rest VAS 0/10
Running pain VAS 8/10

Type of Running: sprint runner covers 15-20 miles per week. Professional runner 100, 400
500m.
Last running was done 2 weeks before pain started after 2 miles.

Sleeping: no discomfort.
Morning stiffness: nil

REDFLAG

any vascular impairment redness/ swelling: nil

tingling: nil
P & N: nil
fever: nil (no signs of septic arthritis/ inflammatory arthritis)
No cyst (no lymphadenoma/ bakers cyst sign)
No bony prominence
night sweat: nil
weight loss: nil
no bony prominence or cyst: nil
No sensory issues
No previous # or evidence of osteoporosis or the Ottawa Knee rule

The Ottawa Knee Rule: A knee X-ray series is only required for knee injury patients
with any of these findings: age 55 or older OR isolated tenderness of the patella (no
bone tenderness of knee other than patella) OR Tenderness of the head of the fibula
OR cannot flex to 90 degrees OR unable to bear weight both immediately and in the
emergency room department for 4 steps (unable to transfer weight twice onto each
lower limb regardless of limping) (Stielle et al., 1993)

In this case, it’s totally uncommon to look for DVT, even though DVT can be associated with
congenital heart failure, varicose vein, smoking, and drug induced. Anyhow the patient is not
having any DVT signs (Kim et al., 2019). Patient haven’t shown any of the signs of DVT.

Signs of DVT

1. Calf muscle band like structure

2. Discolouration in calf muscle.
3. swelling
4. soreness in calf
5. Homan’s sign positive (calf pain at dorsiflexion of the foot) Passive,
abrupt and forced ankle dorsiflexion with slight knee flexion causes
mechanical traction on the posterior tibial vein. This traction
stimulates the pain sensitive structures in the lower limb.
As the posterior aspect of the knee, a lot of structures passing through; nerve route, lymphatic
drainage, synovial space. Initially, neuro/ vascular and lymphatic is clear.

PMH: THREAD: Denies.

Ca: denies.
#: denies.

Medication: Nil

SH: no alcoholism or smoking

OH: Desk based job, full duties, and no restrictions.

Hence the patient cleared that there is no evidence of reflags. We moved to the SHOULD
investigation based on the above information:
OBJECTIVE

L Full knee flexion, extension, and tibial rotation in knee.

L active Hip full flexion was limited in EROM,
L hip extension, abduction, and adduction full

Lumbar spine examination, bilateral anterior pelvic tilt causes tension in hamstring (Thomas
et al., 2016).

L SLR can hold it for 10 second in 45 degrees. 80 degrees have localized pain at hamstring,
Pain at greater than 70 degrees of hip flexion. It might indicate tightness of the
hamstrings, gluteus maximus, or hip capsule, or pathology of the hip or sacroiliac joints
(wang et al., 2009).
As per the image, during SLR concentric contraction of quadriceps and eccentric contraction
in hamstring.
L prone SLR can’t hold it for more than 5 sec due to excruciating pain in the posterior knee.

Tenderness point: grade 3/4 in medially superior to posterior knee joint (according to soft
issue tenderness grading scale)

Soft tissue grading scheme:

0 - No tenderness.
1 - Tenderness to palpation WITHOUT grimace or flinch
2 - Tenderness WITH grimace &/or flinch to palpation
3 - Tenderness with WITHDRAWAL (+ "Jump Sign")
4 - Withdrawal (+ "Jump Sign") to non-noxious stimuli

Warmth: nil comparing both sides of posterior knee joint.

POWER:
L Prone knee flexion is 5/5.
Extension of knee L is 3/4.
Hip flexion L 4/5
Abductors manual resistance 4/5 in L hip

Trendelenburg test: positive in L hip.

A positive test is one in which the pelvis drops on the contralateral side during a single leg
stand on the affected side. This can also be
identified during gait: compensation occurs by
side flexing the trunk towards the involved side
during the stance phase on the affected
extremity

Gluteus medius and minimus are the primary

abductors of the hip. When fully weight
bearing, they act to abduct the femur away from
the mid-line of the body and provide stability of
the hip and pelvis (Palastanga et al., 2012)

The Trendelenburg Sign is often seen in patients

with hip abductor weakness, Youdas et al. (2010)
evaluated the Trendelenburg Signs validity to
diagnose hip osteoarthritis. They found
a sensitivity of 55% and a specificity of 70%.

Squatting couldn’t hold for more than 10 sec

as the prime muscle involved is gluteal max. Medius, hamstring and quadriceps.
Popliteal tendon test: Negative
To test the popliteus, the patient can be placed on his back on the table with the knee in a
90-degree flexion and the foot in dorsiflexion. To test the popliteus, the therapist then
must going push the foot and under leg externally while the patient must maintain his
position. Pain in the posterior aspect of the knee is positive to the test. (Petsche et al.,
2002)

The limitation of this test is not undergone the investigation for diagnostic validity and
reliability of the test. This gap may consider as future recommendation for research
scope.

Anterior Cruciate Ligament (ACL) – Lachmans Test Negative

The Lachmans Test is an anterior draw of the tibia on a stabilised femur at 15-30 degrees of
knee flexion, primarily looking for signs of instability.

Numerous studies have examined the sensitivity and sensitivity of the Lachmans test with
results ranging from 80-99% for sensitivity and a specificity of 95%. Adaptations can be
made for those examiners with small hands or patients with large legs. (Malanga et al., 2003)

Posterior Cruciate Ligament (PCL) – Posterior draw test: Negative

A therapist facilitated posterior draw of the tibia on the femur. With the knee in the same
position as the Sag Sign test, the tibia is first glided anteriorly relative to the femoral condyles
and then posteriorly, looking for signs of instability compared to the opposite leg.

The literature suggests a sensitivity of >90% and specificity of <95%, increasing with these
percentages when used in combination with the Sag Sign test. (Malanga et al., 2003)
Collateral ligaments – medial and lateral stress tests (MCL/LCL): Negative

The collateral ligament tests stress the knee into a valgus/varus direction between 0-30
degrees of flexion, looking for pain and laxity. (Malanga et al., 2003)

Meniscal Tests – McMurrays: Negative

The McMurrays test aims to approximate the

femoral condyle with the tibial plateaux,
thereby compressing and then sheering
across the meniscal surface, looking for
clicking sensation and pain. There have been
several modifications of this test through the
years, making direct comparison of research
studies difficult.

There is a wide variation in the reported

sensitivity (16-58%) and specificity (77-
98%) of the McMurrays test for detecting
meniscal tears. It is thought to still be useful
when combined with other special tests and
subjective finding. (Malanga et al., 2003)

IR and ER of tibia, positive with pain/ audible sound in knee

Bend knee test: positive

Cacchio et al. (2012) evaluated the reliability and validity of the Bent knee stretch test
to diagnose proximal hamstring tendinopathy in athletes with the presence of
symptoms for at least 6 months. They compared their findings to the clinical diagnosis
of an expert physician confirmed by means of MRI and found both a high intra- and
inter-rater reliability above 0.8 and good accuracy with a sensitivity of 84% and a
specificity of 87%.

Picture adapted from physiopedia; resistance applied to knee extension in the position of 90-
degree knee flexion and hip flexion. Positive with pain in the hamstring

Hamstring Eccentric Mid-Range Strength Test: positive

The player is lying prone. The clinician raises the heel one foot length above the examination
table holding the HHD vertically/ manual pressure can apply against the player’s posterior
heel. The player performs 3 isometric knee flexion for 3 seconds. (Maximal effort – hard as
possible). The inter device correlation showed good validity, ICC=.823 (CI, .58-.93) and .840
(CI, .58-.93) for left and right peak torque/forces, respectively. (Lodge et al., 2020)
Pain / weakness can cause due to hamstring tendinopathy.
ASSESSMENT

The initial assessment of the patient has all the signs and symptoms of Hamstring proximal
strain.

CLINICAL REASONING FOR HAMSTRING STRAIN IN RUNNERS

The study concluded that a hamstring injury is most likely to occur during the stance phase
when comparing a normal running technique with a technique in which the subjects run with a
forward trunk lean. These results are in line with the findings of Prior et al., who reported that
an anterior trunk sway during single leg stance, like positions which occur in pivoting sports
(football/ soccur), increased hamstring strain. However, strain on the hamstring muscles and
injury conditions during running with a forward trunk lean may differ from a normal running
technique as the forwards trunk lean elongates the hamstring muscle causing more strain.
Interestingly, a forward trunk lean had the greatest impact during the stance phase with
the knee fully extended, like the stretch-type injury mechanism. The forward trunk lean
can be caused by poor activation and control of the muscles of the core and hip, thereby
increasing the strain and injury risk of the hamstrings. For this reason, an in-depth knowledge
of this type of injury is imperative and could be implemented in hamstring injury prevention
and rehabilitation programmes, focusing on hip and core strengthen. (Danielsson et al., 2020)

Weakness in the GMed has been associated with HSI suggesting that an increase in hip
adduction and difficulty controlling contralateral pelvic drop places additional strain on the
hamstrings. (Sullivan et al., 2022)
As the chart mentioned her, in this case, patient is having weakness in GMed and GMax
hence more chances of getting over load to the hamstring in Initial contact phase.

CLINICAL REASONING FOR SX EXAGERATED AFTER FOOTBALL

A stretch-type injury to the hamstrings is caused by extensive hip flexion with an extended
knee. Hamstring injuries during sprinting are most likely to occur due to excessive muscle
strain caused by eccentric contraction during the late swing phase of the running gait cycle
(Danielsson et al., 2020)
TREATMENT (Schmitt et al., 2012, Hickey et al., 2022)

A progressive return to high-speed running and sprinting is likely the most important aspect
of rehabilitation, given that it is fundamental to performance in many sports and a common
HSI mechanism. Figure provides an example of a 3-stage progressive running protocol based
on our collective clinical experience, understanding of biomechanical demands placed on the
hamstring during running, and application of similar protocols in HSI rehabilitation. Stage 1
can be safely introduced after athletes can walk with minimal pain (eg, pain ≤4 on a numeric
rating scale ranging from 0 to 10), progressing from a slow jog (approximately 25% of
maximal velocity) to moderate-speed running (approximately 50% of maximal velocity) as
tolerated. When moderate-speed running is tolerated, athletes can gradually progress through
stage 2 but should only advance to stage 3 when high-speed running (approximately 80% of
maximal velocity) can be performed without pain to minimize the HSI risk. During stage 3,
progression toward maximal sprinting (100% of maximal velocity) should occur in relatively
small increments (approximately 5%) to account for the substantial increase in negative (ie,
eccentric) work required by the hamstring at running intensities >80% of maximal velocity.

Example of 3-stage progressive running protocol over 100 m, accounting for greater
acceleration distances and more gradual-intensity increases at higher percentages of
maximal velocity.
PHASE 1
Goals
1. Protect healing tissue
2. Minimize atrophy and strength loss
3. Prevent motion loss
Protection
Avoid excessive active or passive lengthening of the hamstrings
Avoid antalgic gait pattern
Ice
2–3 times daily
Therapeutic exercise (performed daily)
1. Stationary bike
2. Sub maximal Isometric at 3 angles (90°, 60°, 30°)

Isometric knee flexion in seated position

3. Single leg balance
4. Balance Board
5. Soft tissue mobilization (STM) to hamstring, gluteus and qudriceps
6. Progressive hip strengthening; bridging
7. Gluteal muscle isometrics and theraband exercise

8. Pain-free isotonic knee flexion

9. Active sciatic nerve flossing

10. Icing to hamstring and compression stockings to knee

Criteria for progression to next phase
1. Normal walking stride without pain
2. Pain-free isometric contraction against submaximal (50%-75%) resistance during prone
knee flexion (90°) manual strength test
PHASE 2
Goals
1. Regain pain-free hamstring strength, progressing through full range
2. Develop neuromuscular control of trunk and pelvis with progressive increase in movement
speed preparing for functional movements
Protection
Avoid end-range lengthening of hamstrings if painful
Ice
Post-exercise, 10–15 min rest and icing
Therapeutic exercise (performed 5–7 d/wk)
1. Stationary bike
2. Treadmill at moderate to high intensity (progressive increasing intervals), pain-free speed
anc stride
3. Isokinetic eccentrics hamstring
4. Single-limb balance windmill touches without weight

5. Single leg stance with perturbation (eg ball toss, reaches)

6. Supine hamstring curls on swiss ball

7. STM to hamstring/ gluteus

8. Nordic hamstring exercise

9. Shuttle jumps

10. Prone leg drops

11. Lateral and retro bandwalks

12. Sciatic nerve tensioning
Criteria for progression to next phase
1. Full strength (5/5) without pain during prone knee flexion (90°) manual strength test
2. Pain-free forward and backward jog, moderate intensity
3. Strength deficit less than 20% compared against uninjured limb
4. Pain free max eccentric in a non-lengthened state
PHASE 3
Goals
1. Symptom-free (eg, pain and tightness) during all activities
2. Normal concentric and eccentric hamstring strength through full range of motion and
speeds
3. Improve neuromuscular control of trunk and pelvis
4. Integrate postural control into sport-specific movements
Protection
Train within symptom free intensity
Ice
Postexercise, 10–15 min, as needed
Therapeutic exercise (performed 4–5 d/wk)
1. Treadmill moderate to high intensity as tolerated
2. Hamstring dynamic stretching

3. Isokinetic eccentric training at end ROM

4. STM to hamstring, glut
5. Plyometric jump training

6. 5–10-yard accelerations/decelerations
7. Single-limb balance windmill touches with weight on unstable surface

9. Sport-specific drills that incorporate postural control and progressive speed

10. Agility training

Mini band spinter
Hamstring tantrum

Agility foot work with lateral hop

Criteria for return to sport

1. Full strength without pain in the lengthened state testing position

2. Bilateral symmetry in knee flexion angle of peak torque

2. Full range of motion without pain
3. Replication of sport specific movements at competition speed without symptoms
REFERENCE

Chu, S. K., & Rho, M. E. (2016). Hamstring injuries in the athlete. Current Sports Medicine

Reports, 15(3), 184–190. https://doi.org/10.1249/jsr.0000000000000264

Cohen, S. B., Towers, J. D., Zoga, A., Irrgang, J. J., Makda, J., Deluca, P. F., & Bradley, J. P.

(2011). Hamstring Injuries in Professional Football Players. Sports Health: A

Multidisciplinary Approach, 3(5), 423–430.

https://doi.org/10.1177/1941738111403107

Danielsson, A., Horvath, A., Senorski, C., Alentorn-Geli, E., Garrett, W. E., Cugat, R.,

Samuelsson, K., & Hamrin Senorski, E. (2020). The mechanism of hamstring injuries

– a systematic review. BMC Musculoskeletal Disorders, 21(1).

https://doi.org/10.1186/s12891-020-03658-8

Degen, R. M. (2019). Proximal Hamstring Injuries: Management of Tendinopathy and

Avulsion Injuries. Current Reviews in Musculoskeletal Medicine, 12(2).

https://doi.org/10.1007/s12178-019-09541-x

Goom, T. S. H., Malliaras, P., Reiman, M. P., & Purdam, C. R. (2016). Proximal Hamstring

Tendinopathy: Clinical Aspects of Assessment and Management. Journal of

Orthopaedic & Sports Physical Therapy, 46(6), 483–493.

https://doi.org/10.2519/jospt.2016.5986

Hickey, J. T., Opar, D. A., Weiss, L. J., & Heiderscheit, B. C. (2021). Current Clinical

concepts: Hamstring Strain Injury Rehabilitation. Journal of Athletic Training, 57(2).

https://doi.org/10.4085/1062-6050-0707.20

Lodge, C., Tobin, D., O’Rourke, B., & Thorborg, K. (2019). RELIABILITY AND

VALIDITY OF A NEW ECCENTRIC HAMSTRING STRENGTH

MEASUREMENT DEVICE. Archives of Rehabilitation Research and Clinical

Translation, 2(1), 100034. https://doi.org/10.1016/j.arrct.2019.100034

McFadyen, B. J., & Winter, D. A. (1988). An integrated biomechanical analysis of normal

stair ascent and descent. Journal of Biomechanics, 21(9), 733–744.

https://doi.org/10.1016/0021-9290(88)90282-5
NICE. (2020). Sprains and Strains. NICE. https://cks.nice.org.uk/topics/sprains-strains/

O’Sullivan, L., Preszler, J., & Tanaka, M. (2022). Hamstring Injury Rehabilitation and

Prevention in the Female Athlete. International Journal of Sports Physical

Therapy, 17(6). https://doi.org/10.26603/001c.38254

Palastanga, N., & Soames, R. (2012). Anatomy and Human Movement: Structure and

Function. In Google Books. Churchill Livingstone.

https://books.google.co.uk/books/about/Anatomy_and_Human_Movement.html?id=OOjGM

gEACAAJ&redir_esc=y

Palpation Examination. (n.d.). Retrieved March 3, 2024, from

https://www.albertapt.com/df_media/W1siZiIsIjIwMjEvMDIvMDEvMTkvMDIvMz

UvYjI5ZTgzZmQtNDExZS00MmJlLWE5ODgtZjdhNTNlYzdiN2UwL1BhbHBhdGl

vbiBFeGFtaW5hdGlvbi5wZGYiXV0/Palpation%20Examination.pdf?sha=dd42f4b89

871b06b

Physiopedia. (2019). Hamstring Strain. Physiopedia. https://www.physio-

pedia.com/Hamstring_Strain

Randall, I. (2021, July 13). Running with your trunk tilting too far increases risk of injury.

Mail Online. https://www.dailymail.co.uk/sciencetech/article-9783707/Exercise-

Running-trunk-tilting-far-increase-risk-knee-pain.html

Schmitt, B., Tim, T., & McHugh, M. (2012). Hamstring injury rehabilitation and prevention

of reinjury using lengthened state eccentric training: a new concept. International

Journal of Sports Physical Therapy, 7(3), 333–341.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3362981/

Special Tests. (n.d.). Allied Health Professionals. Retrieved March 3, 2024, from

https://ahpsuffolk.co.uk/clinical-education/knee/special-

tests/#:~:text=An%20overall%20summary%20of%20the

White, K. E. (2011). High hamstring tendinopathy in 3 female long distance runners. Journal

of Chiropractic Medicine, 10(2), 93–99. https://doi.org/10.1016/j.jcm.2010.10.005

Thank you!