PFATS Articles

Case Study of a Grade III Proximal Hamstring Strain in an NFL Cornerback

Paul B. Sparling, MEd, ATC
Cincinnati Bengals
Cincinnati, Ohio

Hamstring strains are common among skill players in the National Football League. The majority of these are low grade strains which require little if any time lost. Although rarely does a grade III hamstring strain injury occur, but when it does, it is a severely debilitating injury. In 2001, the NFL Cincinnati Bengals had 2 players suffer this injury. Both players had surgical repairs, underwent an aggressive rehabilitation program, and eventually returned to the field.

This case study will present a video record of a grade III hamstring strain in an NFL Cornerback, view MRI findings, review the rehabilitation protocol followed, along with a video record of a segment of his rehab activities, and discuss the eventual outcome.

Anatomy
The hamstring muscle group is comprised of the biceps femoris, semimembranosus, and semitendiniosus, all which originate from the ischial tuberosity. The biceps femoris has two heads, with the long head originating on the lower medial aspect of the ischial tuberosity, and the short head originating on the lower half of the linea aspera and outer condyloid ridge of the femur. The biceps femoris inserts on the fibular head, and the semimembranosus, semitendiniosus, and biceps short head all insert on the medial tibial condyle.

Background
This case involves a 27 year old, 5'7" 185lb. cornerback in his 3rd year in the National Football League. The injury occurred in the second quarter of a home football game at Paul Brown Stadium against the Cleveland Browns while attempting to make a tackle on a natural grass field. The injury was to his left proximal hamstring when his left hip was forcibly hyper-flexed, his right knee was fully flexed underneath him, and both the ball carrier and a fellow tackler landed on his back. He reportedly felt a sharp pulling and burning sensation in the back of his left leg and buttock.

On-Field Evaluation
Physical exam began within a minute of the onset of the injury. Of incidental note, his helmet came off during the play however no head or neck injury occurred. The player was in significant pain and was able to accurately describe the location of his pain as the entire posterior of his left leg with emphasis in his left buttock. The player was rolled onto his stomach and palpation of the affected leg revealed a significant defect in his left proximal hamstring. When the player was ready, he was assisted off the field with a cart and was taken into the training room for further evaluation and treatment. With confirmation of the palpable and visible defect in his proximal hamstring, he was taken to the open MRI facility in the Paul Brown Stadium for a magnetic resonance imaging study.

Diagnostic Findings and Surgical Procedures
The MRI results were available within 30 minutes and confirmed the original impression of a complete rupture of the proximal origin of the hamstring muscle group of the left leg associated with extensive hemorrhage. It was not entirely clear as to whether or not an avulsion of the ischial tuberosity was present or the degree to which the myotendinious junction was involved. Discussion after the game with the player, team Orthopedic Physicians, and Head Certified Athletic Trainer concluded with the recommendation of primary surgical repair. An outside Orthopedic Surgeon (Dr. William Garrett - Chapel Hill) with extensive experience in this type of surgery was consulted who ultimately was requested to perform the surgery.

Surgery was done 12 days post-injury. Visual examination revealed that the common origin of the hamstring was torn from the ischial tuberosity with no boney avulsion. A primary repair was completed utilizing five suture anchors reaffixing the hamstring tendon to the origin. There were no operative complications and no post-surgical issues to note. He was placed in a custom hip spica appliance to immobilize the hip and protect the surgical repair.

Rehabilitation Program
Formal rehabilitation commenced 18 days post-op. The protocol utilized was established by the surgeon and his physical therapist and carried out by the team certified athletic trainer responsible for rehabilitation programs. The protocol was divided into five major phases:

Phase I	(1 - 4 weeks post sx)
Phase II	(4 - 8 weeks post sx)
Phase III	(8 - 12 weeks post sx)
Phase IV	(12 - 16 weeks post sx)
Phase V	(16 - 24 weeks post sx)

Phase I (Weeks 1-4)
This phase was primarily intended to protect the surgical repair while simultaneously gradually regaining range of motion and initiating lower extremity strengthening. The player was non-weight bearing for 2 weeks and then progressed to partial weight bearing as tolerated. Knee range of motion was restricted with a hinged brace to 30 degrees with weekly increases by 10 degrees until full extension was attained.

Walking in a Hydroworx ® Pool in neck deep water commenced once the incision site was healed (about 3 weeks post op). Active hip flexion, abduction and adduction within comfortable range of motion, and passive quad and calf stretching and stretching were also included.

Phase II (Weeks 4-8)
At this stage, weight bearing was progressed to full as tolerated with crutches used until normal gait was achieved. Pool work as continued as tolerated and a stationary bike was added with the seat adjusted up high and no resistance. Gentle passive stretching of knee extension and hip flexion was commenced. Progressive resistive strengthening of the quad, with straight leg raises, short arc quads, sitting knee extension, short squats, and leg press were included, utilizing theraband, ankle weights, and isokinetics as appropriate. Hamstring work consists of prone and standing knee curls with gravity resistance only. Hip strengthening includes hip extension, flexion, abduction, and adduction with ankle weight as tolerated. Emphasis was on closed chain activities

Phase III (Weeks 8-12)
Swimming in the pool was started at this stage, and jogging in the pool gradually working into waist deep water was also included. Duration on the stationary bike was increased, as well as resistance. Isokinetic strengthening was progressed with emphasis remaining on higher repetitions and faster speeds. On-land walking, treadmill work, and stair-stepper with appropriate progression as tolerated were also commenced.

Phase IV (Weeks 12-16)
Jogging on land began at this stage, as well as progression of speed up to running in the Hydroworx ®. Light agilities on land including shuffles, carioca, and back-pedaling began, as well as continued progression with PRE's as tolerated.

Phase V (Weeks 16-24)
On-field agilities included cutting, pivoting, shuttle runs began, as well as backward running to emphasize hamstring control and strength. Isokinetic exercises gradually were phased towards slower speeds and progression to sport-specific functional activities as tolerated and appropriate.

Return to the field
At this stage of this rehabilitation, the player was fully functional on the field with no restrictions. He still felt, however, the need to continue to increase his speed and quickness in advance of the upcoming 2002 Training Camp, and was given permission to work with a speed coach as his rehabilitation program was essentially complete. His pre-injury 40 yard dash time was 4.34. His 40 yard dash time at six-month post injury was 5.01, and at the start of Training Camp was 4.65.

Discussion
At the original time of injury, management inquired as to the likelihood of this player returning to NFL cornerback form. It was predicted that he would return to the field, but his speed and quickness would be ultimately affected by the severity of the injury. This ultimately turned out to be correct, and he was waived in late August. Although he was claimed by two other teams, he was not able to remain with either team for more than a few weeks. After failing to make a team in 2003, he opted to officially retire from the NFL in 2004. He reports that his best 40 yard time was 4.43 at two years post-injury.

A grade III proximal hamstring strain is a very severe injury and is it difficult to predict a return to pre-injury form in the NFL, especially in a skilled-position. While surgical repair is recommended to offer the optimal outcome, the realities are that it remains uncertain as to the full and complete return of speed, agility, quickness, and burst necessary to be an effective NFL cornerback.

References:

1. Clanton TO, Coupe KJ. Hamstring strains in athletes: diagnosis and treatment. J Am Acad Orthop Surg. 1998 Jul-Aug;6 (4):237-48.
2. Best TM, Garrett Jr WE. Hamstring Strains: Expediting Return to Play. The Physician and Sports Medicine. 1996 Aug (Vol 24-No.8).
3. Klingele KE, Sallay PI. Surgical Repair of Complete Proximal Hamstring Tendon Rupture. Am J Sports Med. 2002 Sept 1.