Hamstring injuries, how to limit time loss. Hamstring injuries are not going away, they're getting more injuries than before, the injury rates are increasing in European football, 20% of the major league soccer and 20% of those are chronic. The risk factors, there's many of them, but the big four to me are hamstring strength difference between 10-15%, dehydration, fatigue that leads to overexertion, and a history of prior injuries, 2-6 times greater chance of getting it. Initial workup, did you have a hamstring injury before, the most important question, where, the location, if it's mid-belly, we usually use ultrasound, if it's anywhere else on either side we use MRIs, especially the distal T-zone of the short head and long head of the biceps which is a really bad area. Does the MRI help to predict return to play, yes, almost all the studies say yes, only one study said no. Stevie Cohen with me, he was with the Eagles, we looked at MRIs with age, number of muscles involved, location of injury, presence of insertional damage, percentage of cross-sectional area involvement, length of muscle retraction, long axis T2 sagittal plane injury, and presence of chronic changes. What we found were three distinct groups, the group that was out for less than one week had a proximal or mid-injury that was less than 25% of the muscle, one to two weeks were multiple muscles or distal muscle tendon junction, greater than three weeks they had retraction and greater than 75% of the muscle was involved with musculotendinous cysts. This is the Steeler grading system, it's in the handout, it's uploaded so you can see it, this is how the Steelers use it. There are other grading systems, this is the British Athletic Muscle Injury Classification, I think you should look at, they grade them from grade zero to grade four. Classification, you got to do, you got to, the mechanism first, direct or indirect, which muscles involved, that makes, that's important, is it a tendon or is a muscle tendonous junction, you got to grade it by whatever grading system you're going to use, we like to use the Steeler one, and then is there recurrence, is this a recurrent injury, because that's a big factor. This is why I use ACP, Gus Mazzocca and Bob Arciero and I published this study, and what we found with autologous conditioned plasma, the myocyte proliferation significantly increased when we used it. And these are the things that, further studies are out there, that these are the factors, especially incident-like growth factor, where keys in muscle regeneration, and ACP has every one of those growth factors. First there are animal models, this is when it first interested me, the animal model, so there was a seven-day decrease in return to sport in the animal model, then Wright Carpenter came out and found the same thing in a human study, meaning of seven days earlier with the use of autologous conditioned plasma. Then we looked at our 10-year study of grade two hamstrings only, and I was the only, one musculoskeletal radiologist, and I was the one injecting them, we had 108 players over that time, 69 had grade two injuries, we did basically half and half, 30 ACP, 39 no ACP, and what we found out, the studies published, we found out there was a one-game difference, so the one game in the NFL is a lifetime, if it's your wideout that's a match-up nightmare, or your quarterback, so just to save one game, we had no re-tears. Then Stevie Cohen came out, him and Chris Dodson with the Eagles, and they showed in 2002 that with their using platelet-rich plasma, their return was nine days earlier, their re-tear rate went from 26.6% to 4%, and that's a reason to do it alone, because a re-tear is a disaster. So the treatment, grade zero, we just rehabilitate them, grade one, we use one shot of leukocyte poor platelet-rich plasma, 24 to 48 hours after the injury, ultrasound-guided, if it's a grade two or three, we use three ultrasound-guided injections over a three-week period, if they're better after the second one, we don't do the third one. Any proximal or distal injury is either surgery, and very rarely it's platelet-rich plasma in my hands, it's typical surgery. The Steeler protocol is well-established, we use rice, the NSAIDs don't make a difference with platelet-rich plasma, I did that study, stem stretching, blood flow restriction is very helpful, Nordic exercises, BFR, and Nordic falls for the remainder of the year, so the Nordic exercises are key. Don't forget OrthoGold, which is extracorporeal shockwaves help platelet-rich plasma, we use a Haskins H-test or a Norboard test, and then a gradual return. With the Steelers, we use Catapult or Zebra GPS systems, they have to be within one mile an hour of their prior speed, their annular accelerations have to be nearly the same, and their total work has to be the same before we send them back on the field. Start to worry when you get a player that's at his total workload three days in a row, the chance of him getting hamstring injuries are really high, so if they're three days in a row and they're maxing out, you got a problem. There's other papers out there that show that the evidence-based hamstring injury prevention and risk management are that eccentric strengthening reduces injury incidence, improves hamstring strength, fascicle length, hamstring quad ratio, limb symmetry, and stretching-based interventions can be implemented to improve flexibility. They like BFR and body vibrations and plyometrics. Rehab protocol, very important to use a gradual strain based on the program, which works on restoring length, Marcel will tell you all about that, we go through this all the time, but not with excessive strain early. Excessive strain stimulates transforming growth factor beta, and that increases scar formation. Our goals are zero within seven days, grade one, seven to 14, grade two, 14 to 21, grade three, 21 to 28, grade four, up to three months, surgery for most tendon injuries, if it's a re-tear, you can almost increase the time by a third. Here's my key points, transforming beta stimulates fibrotic scar, and you want to stop it after about 96 hours, okay? No cortisone, cortisone's great for blocking transforming growth factor, but it's bad on muscle regeneration, so you get a little hole. No Losartan, because I don't think the literature is high enough, Losartan's a blocker, it's an antihypertensive. All exercises are close to being pain-free, so don't load the tissue beyond its elastic limit, because it's going to form scar. Thank you very much.

hamstring injuries

time loss

European football

chronic injuries

autologous conditioned plasma