Hamstring Strains, Lumbar Pain, And Clinical Reasoning

As a clinician working with a sports population, I have seen my fair share of what I would call traditional hamstring strains. They are common in sports that involve sudden acceleration and/or deceleration.

These types of problems may appear to be simple to sort out as you listen to the patient history. Pattern recognition is important in the clinical reasoning process – but with that said, attention must be paid to those aspects of the clinical picture that don’t fit the pattern.

It is easy for clinicians to lose sight of one simple fact: the lumbar spine can refer pain throughout the lower extremity and can produce signs and symptoms that can mimic virtually any lower extremity disorder. We can thank our neurological “wiring” for this phenomenon. Understanding the behavior of the system under mechanical loading becomes critical for an accurate mechanical diagnosis, and subsequently an appropriate treatment intervention.

Over the past few months, I have seen quite a number of “hamstring strains” that were really a wolf in sheep’s clothing. They were lumbar spine issues that were mimicking hamstring signs and symptoms.

The patient history in these cases is often very similar. The patient may report feeling a “pop” or “rip” with an activity. They will often report very localized pain at the muscle’s origin: the ischial tuberosity. They may present with constant symptoms initially thought to be indicative of a potential inflammatory response. Resisted testing of the hamstring muscles reproduces not only concordant pain, but weakness as well. They may even claim to note palpable tenderness at the ischial tuberosity. Straight leg raising reproduces concordant symptoms and is limited.

Before you are ready to head off and grab an ice pack or an ultrasound machine, remember this: all of the pieces of the puzzle have to fit. Right now, the picture looks clear, but there are still some pieces of the puzzle that need to be further addressed mechanically.

From a clinical reasoning perspective, any lower extremity problem demands a simple ruling-out of the lumbar spine. In all of these cases, there was noted to be a minimal or moderate loss of extension of the lumbar spine with movement testing.

Hmmmm. Could be important, but perhaps not. Let us continue with the thought process.

Repeated movement testing provides us with a reliable and consistent means of collecting data on the effects of mechanical loading. This will provide important information in the clinical reasoning process. If repeated movement testing of the lumbar spine is negative (i.e. signs and symptoms remain unaffected), then feel free to focus on the localized issue. But if repeated movement testing of the lumbar spine is positive (i.e signs and symptoms are affected with repeated movements of the lumbar spine), then your “hamstring strain” may not in fact be a “hamstring strain”.

In the cases I mentioned above, something very intriguing took place after repeated lumbar extension movements. First of all, there were immediate changes in leg symptoms. Palpable tenderness was immediately diminished, even though nothing was done to directly affect the “tissue”. Straight leg raising became less painful and movement improved. Resisted testing of the hamstrings was now painfree and strong.

So was this truly a hamstring strain? Was it an issue of tissue repair and remodeling? Or was it a problem with mechanical loading of the lumbar spine?

The lesson learned in the clinical reasoning process is simple: instead of trying to “rule-in” a diagnosis, attempt to “rule-out” as many as possible. The most common source of lower extremity symptoms is the lumbar spine; not ruling it out leaves a lot of options (red herrings and otherwise) on the clinical reasoning table. Don’t get caught trying to jump to a quick conclusion based on some pieces of a pattern that you think you recognize – due diligence in the clinical reasoning process is necessary and will ultimately improve the outcome for the patient.

Photo credits: procsilas