Hamstring Sprain / Tendinopathy - Removemypain

Hamstrings are a group of muscles present at the back of the thigh. They extend from the sit bones in the pelvis to just below the knee joint and play an important role in daily activities such as walking & running. The names of the individual three muscles included in hamstrings are semimembranosus, biceps femoris, and semitendinosus. These, work in opposition to the muscles in the front of the thigh (quadriceps) and the two groups of muscles together stabilize movements of the knee and pelvis.

INCIDENCE

Hamstring injuries account for approximately 12–16% of all injuries in athletes. They are seen more commonly in sports that involve sprinting, acceleration, deceleration, rapid change in direction and jumping such as football, basketball, rugby and baseball. Runners, ballet dancers and older adults who do a lot of walking are also at increased risk. Reinjury rates are high and generally require more time away from the field. Although any injury for a sportsperson is painful, this one can be quite frustrating for both the sufferer and the treating physician.

SYMPTOMS

Symptoms vary depending on the severity of the problem. When the upper part of hamstrings is involved the most common symptom is deep buttock pain or irritation at the back of thigh (minor sprains) associated with tightness or cramping sensation. Pain can radiate down the back of thigh and is generally aggravated by physical activity such as walking, running uphill, high speed or long distance running, leaning forwards, squats and sitting on a firm surface for long duration. Morning increase in severity of pain is not uncommon in this condition. In the early stages pain may reduce after warm up and then recur after activity. This changes with time with the pain persisting throughout the day.

Partial or complete tear of hamstrings may present with severe stabbing pain, bruising with inability to weight bear or walk. Sciatic nerve is present close by and its irritation can cause pain to radiate further down the leg. In severe cases the tendon may completely tear away, often taking a piece of bone with it and this is addressed as avulsion injury.

RISK FACTORS & BIOMECHANICS

Muscle attaches to the bone with the help of a special type of tissue called tendon. To simplify, you can look at these as ropes tying the muscles to the bones. Injuries can involve the muscles or the area where the muscle transforms into the tendon (myotendinous junction) or the tendon itself. Generally the closer the injury is to the pelvis / sit bones the longer it takes to heal. Of the three muscles, biceps femoris is the most commonly injured one.

The hamstrings cross two joints and help to bend the knee and move the hip backwards (extension). They play an important role in propelling the body forwards as we move. Hamstring injury may occur by high speed mechanisms such as running or low speed mechanisms such as stretching. Sudden loading of muscle while it is stretched as while kicking a football is also a common injury mechanism.

The risk factors most consistently associated with hamstring muscle strain-type injuries are age, previous hamstring injury and quadriceps peak torque. As mentioned previously hamstrings and quadriceps oppose each another and it is not uncommon to see imbalance between the two groups of muscles with the latter being stronger. This is expressed as low hamstring to quad ratio which essentially means weaker hamstrings. Weak hamstrings can quickly turn into tight hamstrings and require hamstring to work harder which tires them easily. Tight, tired and weak muscles are predisposed to injuries. When the hamstring are injured, other nearby body muscles are called into action such as those in lower back and hip predisposing them also to injuries/ pain.

Risk factors foe hamstring injury can be classifies into modifiable and non-modifiable ones.

Modifiable risk factors

• Volume of training and rapid variations
• Muscle fatigue
• Weak hamstrings
• Repeated overloading with insufficient warm-up
• Over striding during running or abruptly changing direction
• Lower back, core and pelvis weakness or trunk instability
• Prolonged sitting (work, cycling etc)
• Biomechanical issues such as unequal leg length

Non-Modifiable risk factors

• Previous hamstring injuries – most consistent risk factor with two to six times increased risk of recurrence. Most repeat injuries occur within two months of return to the sport but the risk remains elevated up to three times for an year after initial injury.
• Age – teens and young adults are more likely to experience hamstring injuries as muscles do not tend to grow at the same speed as bones. Aging adults are also at a higher risk possibly due to reduced muscle cross-sectional area.
• Genetics (collagen types)

HAMSTRING INJURY GRADES

Most hamstring injuries occur in the thick, central part of the muscle or where the muscle fibres join tendon. Muscle strains are graded from 1 to 3 depending on their severity

Grade 1 – or hamstring pull is most minor form and usually heals readily. Most patients with this are able to walk easily although may notice pain at the back of the leg after prolonged or quick walking.

Grade 2 – this is associated with more pain (often shooting type) and patients may struggle to walk / limp.

Grade 3 – represents more marked muscle tears including complete tears which present with more severe pain, swelling and difficulty weight bearing. These may require several months of rehabilitation.

INVESTIGATIONS

MRI scans can help confirm the diagnosis, assess severity of the problem and estimate recovery time. Proximal injuries close to pelvis and those involving increased length and cross-sectional area require longer rehabilitation.

Ultrasound scans are an alternative although are not as reliable in assessing deep portions of the muscles and are unable to identify bone oedema.

TREATMENT

Most hamstring injuries can be managed conservatively. This includes using a combination of rest, activity modification, physical therapy and medications such as anti-inflammatory drugs. Activity modification will depend on the severity of problem and does not imply complete inactivity. Approximately 20% of people with proximal hamstring tendinopathy have residual pain despite conservative management and may require further treatment such as injections.

Injection options include

• Percutaneous tenotomy
• Platelet Rich Plasma (PRP)
• Steroids

Ultrasound-Guided Percutaneous Needle Tenotomy

This is used for patients with refractory symptoms and is often in combination with the PRP treatment. It is an OPD procedure performed under local anaesthesia and ultrasound guidance. The aim of the procedure is to create an injury in the tendon by repeated punctures. As a result blood and platelets flow to the area increases, thereby promoting release of growth factors and promoting healing.

Ultrasound-Guided Platelet Rich Plasma (PRP) Injection

PRP injections are commonly used for treatment of hamstring tendinopathy and the evidence supporting their use is slowly accumulating. The procedure involves drawing out patient’s blood and placing it into a spinning machine which separates the platelets from the other blood components. This concentrated platelet layer containing growth factors is then injected into the problem area to induce tissue healing and regeneration. These injections take time to work with benefits becoming apparent 6 to 12 weeks after treatment. My practice is to perform PRP injections under ultrasound guidance and combine these with the needle tenotomy procedure mentioned previously. These injections are used in in combination with lifestyle modification and physical therapy.

Ultrasound-Guided Steroid Injection

These injections can be beneficial for some patients with chronic hamstring tendinopathy and are best avoided in treatment of acute hamstring injuries. Ultrasound guidance helps to improve the safety and accuracy of injections. The aim of thee injection is to deposit steroids in close proximity to the problem area- targeting the area around the tendon (peritendinous) and the overlying bursa. Steroids by their anti-inflammatory effects help to reduce pain, inflammation and improve sitting tolerance, provide a window of opportunity for rehabilitation.

PHYSICAL THERAPY

This is an important component of treatment irrespective of whether injections are performed or not. Continuous exercise program focusing on progressive eccentric hamstring strengthening and core stabilization is commonly used with expected recovery times from 1-3 months in majority. Other treatment goals include correcting postural imbalances and improving tissue mobility. Working on the gluteal muscles is equally important, as these are the strongest hip extensors and can assist in reducing/ sharing the hamstring load.
Different phases of rehabilitation have been described for grade I and II hamstring strain injuries.

Phase 1: Focusses on protection, ice, anti-inflammatory drugs, improving soft tissue mobility via manual therapies and therapeutic exercises. In this phase one can initiate non-provocative core strengthening and gluteal and hamstring isometric exercises under guidance of a specialist. Isometric exercises contract muscles without moving them as while squeezing the buttcheeks. Progression to phase 2 occurs when able walk a normal stride without pain and when very low speed jogging is tolerated.

Phase 2: Different exercises called concentrics with shortening of muscles (such as hamstring curls) are added in this phase. End range movements are avoided.Anaerobic training and sports skills can be initiated with care, in the phase. Progression to next phase is considered when forward and backward jogging at 50% maximum speed is possible without pain.

Phase 3: In this phase, the range of exercises is increased and eccentric exercises are added. Eccentric exercises are those in which a muscle is contracting while lengthening. An example would be when one is lowering the weights down in a controlled fashion during a hamstring curl. These exercises help in strengthening and remodeling tendons.
Modalities such as soft tissue mobilization and Extracorporeal Shockwave Therapy (ESWT) may be utilized along with exercises. Shockwave therapy delivers a small amount of controlled micro-trauma to the affected tendon. In order to reinitiate the natural healing process. Generally, 3-5 sessions are required to reduce pain.

Surgery may be required to deal with severe cases such as avulsion injuries or complete/extensive partial tears not responding to other treatment options.

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Tag =  Sport Injury Treatment in Delhi, Treatment Of Hamstring Strain

A New Treatment For Frozen Shoulder Ultrasound Guided Capsular Hydrodistention - Removemypain

 

What is frozen shoulder?

Frozen shoulder is a shoulder pain condition where there is significant loss of motion of the shoulder joint accompanied by stiffness. The shoulder joint is surrounded by the strong capsule and the main problem in this condition is believed to be the tightening of this capsule. The resulting pain is generally deep seated and poorly localised. It may be constant or present only at night when lying on the affected side. All movements of the joint are affected, especially the ones involving reaching straight up and rotation of joint such as while reaching behind the back.

Frozen shoulder is seen more commonly in women, especially between the ages of 40-60 years. Non-dominant side is more commonly involved, although in 20% to 30% of individuals both sides may be affected. Diabetics have five times more chances of developing this condition and about 30% of people with frozen shoulder have diabetes. Patients with overactive or underactive thyroid or those with shoulder immobilisation (such as after a fracture or stroke) are also at higher risk for developing frozen shoulder.

What is capsular hydrodistention?

Hydrodistention or dilatation or hydrodilatation is a non-surgical procedure aimed at stretching of the tight shoulder joint capsule. This is achieved by injecting saline or a mixture of saline, steroids and local anaesthetics under ultrasound or x-ray guidance. Ultrasound guidance is preferred as it is quicker, can be performed in the OPD and does not involve any radiation exposure. This procedure is an alternative to a surgical procedure – manipulation under anaesthesia (MUA), with some studies indicating better results with hydrodistention.

How is capsular hydrodistention performed?

I perform this procedure under ultrasound guidance in a sitting or lying position. The injection area is cleaned with antiseptic solutions. Ultrasound scan is performed to identify the shoulder joint, its capsule and plan the best pathway into the joint. Local anaesthetic is used to numb the injection site. A fine needle is introduced onto the surface of the shoulder joint under ultrasound guidance. A solution containing saline, local anaesthetic and steroid is then injected below the capsule. As the injection mixture is given, the capsule can be seen lifting off the joint. Once the injection is complete the needle is removed and a small dressing is placed over the injection site. The procedure takes about 20- 30 minutes to complete.

How does capsular hydrodistention work?

Hydrodistension is thought to have a mechanical effect of opening up the joint and releasing sticky adhesions within the joint, although the exact mechanism of action is debated. With stretching, the pressure inside the joint is reduced and the shoulder volume is increased. These effects can help in reducing pain, stiffness and improving the range of motion.

There is research evidence supporting better outcomes with the combination of hydrodilatation with steroids and physiotherapy, compared to either of the modalities when used alone. Hydrodistension results are comparable or better to the surgical procedure manipulation-under-anaesthesia (MUA), although the risks are less. Diabetic patients with frozen shoulder have inferior outcomes and in these hydrodilatation is likely to be more beneficial. In case of incomplete recovery these patients can be considered for repeat injections.

The option of steroid injections directly into the joint is preferred over the oral steroid as they are associated with fewer side effects. Some studies have found that oral steroids are as much as 5 times more likely to give the typical steroid side effects one hears of, compared to the one-off joint injection. Also, the lack of long-term benefits makes oral steroids a less attractive option in this condition.

Tag = Shoulder pain treatment in Delhi, capsular hydrodistention, frozen shoulder, Frozen Shoulder Ultrasound Guided Capsular Hydrodistention

Cervical pain treatment in India - Removemypain

Most individuals with cervical radiculopathy get significantly better within 6-12 weeks, with good recovery in 4-6 months. For some, however, this can be a long-lasting problem. Ignoring persisting symptoms can aggravate the situation leading to chronic pain with reduced functionality. Treatment of this condition required a multimodal approach with a combination of lifestyle changes, medications, physical therapy, and injections. Surgical intervention is required in very few patients and there are specific indications for surgery. The presence of pain alone is not an indication of surgery.

Some of the pain management techniques include:

Lifestyle changes: These include activity modification, giving up smoking, being mindful of one’s posture, and simple ergonomic changes. Incorrect posture while working on laptops, mobiles, etc can cause excessive cervical spine strain with certain professions being more prone to develop neck pain. Simple measures such as adjustment of furniture height and computer position can go a long way in relieving symptoms. Taking regular breaks to walk around and stretch is a good practice.

Medications: Anti-inflammatory drugs, muscle relaxants, painkillers acting on the nerves (neuropathic agents) may all be used depending on the source of pain and severity of symptoms. Sometimes stronger painkillers may also be suggested by your doctor.

EPIDURAL INJECTION (Nerve Block)

The aim of this injection is to deliver the anti-inflammatory medicine in the epidural space, close to the affected nerve. Epidural space is a fat-filled space present in the spine, between the bone and a protective sac around the spinal nerves. Epidural injections are effective procedures and may help in rapid recovery by reducing inflammation. These medicines may also help by reducing the sensitivity of the nerves carrying the pain signals. The relief from these injections may be short-term or long-term, lasting from days to years. In some cases, it may even be permanent if the original problem responsible for pain heals. There is some evidence pointing to recurrence of symptoms in up to one-third of patients with cervical radiculopathy following initial treatment and repeated injections over one year may have a synergistic effect on pain relief. The goal of these injections is to reduce pain so that you can resume normal activities and engage in a physical therapy program.

The procedure involves the following steps

Step 1: Positioning and preparation

An IV drip is placed and the patient is positioned on the x-ray table. Monitors for recording the vital signs such as heart rate, blood pressure, and oxygen levels are attached. The procedure area at the back of the neck is cleaned with antiseptics and drapes are placed around it to keep it clean. Local anesthetic is used to numb the treatment area to reduce any procedural discomfort. The patient remains awake during the procedure as this helps to provide feedback to the physician performing the procedure and enhances the safety of the injection.

Step 2: Performing the injection

The problem area is localized using x-ray guidance. A needle is then slowly directed into the epidural space using real-time x-ray guidance. These x-rays are visualized in real-time on a monitor attaches to the x-ray machine. Once the needle is correctly placed, a dye (contrast agent) is then used to verify the needle position. A mixture of local anesthetic and anti-inflammatory medicine (steroid) is then given. After the injection is complete the needle is removed and a small dressing is applied.

Step 3: Post-procedure

After the procedure, monitoring is continued for some time.  Most people are discharged home after a few hours and are able to resume full activity from the next day. Simple painkillers such as paracetamol can be used for any discomfort around the injection site. The effect of injections can take some days to manifest and keeping a record of how your pain changes are advised. A post-procedure follow-up appointment is usually scheduled after a few days and it is important that you attend this appointment.

Tag = Cervical pain treatment in India, Removemypain, Back Pain Treatment in India

Sport Injury Treatment in Delhi - Removemypain

Overuse and trauma are two common factors responsible for sports injuries. Both intrinsic (such as age, fitness level, muscle strength etc) and extrinsic factors (such as equipment, environment, type of activity etc) play a role in injuries.

Prevention of injuries may involve changing of training schedule, gear, training, practicing environment and style and many other factors. Primary prevention deals with prevention of an injury whereas secondary prevention is about prevention of re occurrence of injury. As "Prevention is better than cure," here are some tips that can help you prevent sports injuries. Whilst most of these may seem like common knowledge, you would be surprised by how many injuries can be avoided by following these tips.

Tip 1: Understand the importance of physical conditioning and know your limits

This factor is often overlooked by amateurs who easily succumb to temptation and overindulge.  It is easy to get carried away when you return to sports after a long time. Knowing ones limits, gradually increasing the intensity and duration of training can help in injury prevention. Regular exercise is an effective way to energize your body and keep fit.  On the other hand aggressive training beyond ones capabilities and the resulting overuse, fatigue, poor judgment makes injuries more likely.

Be mindful of old injuries and listen to your body. Warning signs such as joint pain, tenderness, and swelling are reasons to re-evaluate your technique and routine.

Tip 2: Invest in the right sporting gear

This includes every essential bit of equipment required for playing a particular sport, starting from the right shoes to the protective equipment such as helmets, gloves, protective pads etc. Right gear not only protects you from injuries but can also enhance your performance.

Tip 3: Warm and stretch your muscles

Warmed up muscles are less prone to injuries and overlooking warm-up sessions can cost one dearly. Warm up raises the core body temperature and gears up the body for the intended exercise.  It helps by increasing the blood flow to muscles improving the muscle efficiency, range of motion and stretching the muscles being used in particular sports. Stretching to the point of tension (not pain) helps to reduce stiffness and improve flexibility, thereby reducing the chances of injury.

Warm up may be general or specific to the intended sport.  The right exercises would vary depending on the sports. Starting the sport at a slow pace can be helpful. If you closely observe your sporting idols, you will always see them warm up prior to any game.

Tip 4: Use the right technique and follow the rules of the game

Correct techniques to play a sport are defined to minimize the chances of injuries and maximize your performance. The same can be said about the rules of the game. Incorrect overzealous manoeuvre can predispose one to injuries and hence the importance of concentrating on the precise technique. One example which I can quote as I commonly see this in my clinic is back injuries due to incorrect dead lift technique. Often that temptation to add the extra 5kgs compromises the technique predisposing one to injuries.

Selecting the appropriate surface for sports is equally important especially for repetitive activities such as running, jumping where the impact force on the body is magnified by 3- 12 times. Impact force on hard surfaces is much higher increasing the injury chances. 

Tip 5: Cool down

Cooling down is another injury prevention technique that helps to return the heart rate, breathing, and blood pressure to the pre-training levels. It can also help to limit the post exercise muscle soreness and flush out toxins produced during the training.

Tip 6: Adequate recovery

Adequate recovery is essential no only for avoiding injuries but also for the full training effect. Inadequate recovery can lead to tiredness, lethargy, mental fatigue and impaired performance. Adequate recovery includes warm down sessions, re stand sleep, psychological and nutritional advices.

Tag =  Sport Injury Treatment in Delhi

Cervical Pain Treatment in India - Removemypain

Neck Pain is a pain posteriorly anywhere between the skull base and thoracic spine. It is the largest cause of musculoskeletal disability after low back pain. Approximately two-thirds of the population will suffer from neck pain at some time in their life with high prevalence in middle ages. Fortunately for most people the acute pain resolves within days or weeks although in some it may reoccur or become chronic.

Neck pain may be a result of...

• Local pathology
• Whiplash (flexion-extension) injuries/ trauma
• Be a part of a more widespread systemic problem such as ankylosing spondylitis, rheumatoid arthritis, fibromyalgia etc.
• Be a result of referred pain from neighboring areas for example the shoulder joint

Neck pain usually has a multifactorial etiology -poor posture, neck strain/injuries, anxiety, depression and stress can play a role in magnifying the perceived pain. Quite often the diagnosis of simple or nonspecific neck pain is used implying postural and mechanical causes; this is contrary to other serious causes of neck pain such as fracture, tumour, infection etc.

Pain from upper neck can radiate towards the head leading to frequent headaches and that from the lower part of the neck can radiate to the shoulder, arm, chest wall and the scapula. Reduced neck movement along with localized areas of muscle tenderness known as trigger points are commonly observed along with pain.

Tag = Cervical Pain Treatment in India, Pain Management in Delhi, Back Pain Treatment in India