Biceps Femoris Tear

Introduction

Mr Forest Gump, a long-distance runner has suffered right grade II biceps femoris tear 8 weeks ago. He mis stepped while walking down the stairs and overstretched his leg while trying to stabilize himself. Since then, Gump has not effectively managed his injury and has therefore sought clinical help. He has also not been able to finish any long-distance run but has attempted several short distance runs, albeit with less speed. He says he feels better when resting but the pain increases when walking downstairs, over striding, during any quick response actions or after standing or sitting for a long time. The biceps femoris is a hamstring muscle consisting of a long head and a short head (Ayoub et al, 2020). According to Entwisle et al (2017), the long head comes from the pelvis’ ischial tuberosity whereas the short head comes along femur’s posterior section. Both the long and short heads of the biceps femoris insert into the fibular head and the knee’s collateral ligament, enabling the knee to flex and extend. Therefore, a femoris tear implies that athletes cannot flex or extend their knees while running. By mis stepping while walking down the stairs, Gump excessively irritated his biceps femoris, leading to chronic tendinosis (Kayani et al, 2020). He is therefore not able to engage in any rigorous physical activity (e.g. over striding, walking downstairs, or long-distance running) because this would cause further irritation of biceps femoris. Therefore, he needs some therapy to repair the torn muscle.

Testing Methods

The first diagnostic procedure is to conduct a general observation of the hamstring through palpation to pick up any forms of bruising or asymmetry, which according to Kandel (2020), is an important part of the test because it helps to conduct quicker identification of injuries. The general observations starts by palpating around the proximal hamstring at the ischial tuberosity, which can be a cause of pain, especially the insidious onset hamstring pain that cause proximal hamstring tendinopathy (Takahashi et al, 2017). According to Poudel & Pandey (2020), athletes with more severe injury will have tenderness around the hamstring muscle belly. Therefore, palpating the hamstring muscle belly can help detect any muscle defects or any other more significant problem around the proximal hamstring (Pickel & Swift, 2020). The observation also includes direct visualization of the distal hamstring tendons by having the client pull up their legs on the opposite direction to expose the tendons and palpate them as they insert around the knee, exposing the lateral view of the biceps femoris and the medial view of semimembranosus and semitendinosus (Rodgers & Raja, 2019). The next test involved assessing Gump’s hamstring flexibility by lifting his legs straight and asking them whether he felt any pain as the leg is straightened. He confirmed the existence of some pain. Next, I measured his hamstring angle by flexing both his hip up to ninety degrees and then extended the knee until it could no longer extend further, then measured the distance from the vertical and documented it as an angle of negative 40 degrees. After assessing the hamstring’s appearance, I also did some functional tests to evaluate the hamstring’s strength. I asked Gump to lie prone and have a leg curl so that if I pulled his heels up against me while doing it in different positions, then relaxed. During this movement, Gump reported some pain. Furthermore, I observed a weakness with the hamstring contractions. However, Hatzantoni & Khan (2020) argued that not all patients presenting with acute hamstring injury would have a muscle tear. Therefore, I found it useful to conduct a test that would help ascertain whether Gump had a tear or a more functional problem. To do this, I conducted a slump test on Gump. To conduct the slump test, I asked Gump to sit up and pop his hands behind his back, with his chin down on his chest, slumping down to have a bending posture. I then brought the patient’s ankle into dorsiflexion and straightened his knees to bring it into extension. I then asked him whether that position produces any pain. Gump reported no pain, confirming the absence of any functional problem. This helped deduce that Gump was having an acute muscle tear.

Interpretation

Both the short and long heads of the biceps femoris insert into fibula head and at the point of insertion, they divide into two sections through fibular collateral ligaments. Because by mis stepping as he climbed down the stairs, Gump may have dislocated or subluxated his biceps femoris tendon, leading to the snapping of the tendon (Chang et al, 2020). This explains why he experienced symptoms of pain on the lateral side of his knee as I assessed his hamstring strength. Furthermore, the dislocation explains why he reported a painful snap during active and passive flexion of his knee at 90 degrees – thus the symptoms of pain while standing or sitting for a long time and inability to engage in long-distance running. While running, Gump is likely to experience an abrupt alteration or rise of speed as a result of the hurting of semitendinosus and biceps femoris muscles situated at the back of his thighs, causing those muscles to overstretch (Moatshe et al 2017). The reason why Gump feels more pain when he overstrides or when he walks down the stairs is that during these movements, the hip extends and over-activates of the biceps femoris, causing an abnormal foot strike when the tibia externally rotates (Takahashi et al, 2017). Moreover, running for long-distance increases the risk of overuse injuries on the knee by increasing the foot’s torsional forces during the stance and strike phases of the running stride.

Discussion

Other alternative tests that can be used to diagnose biceps femoris tear is imaging, which helps to define the severity and extent of the injury (Ayoub et al, 2020). Furthermore, Poudel & Pandey (2020) noted that the physician can use plain films to identify any avulsion injury, in which case, it may be apparent that the client has an avulsed bony fragment. However, according to Pickel & Swift (2020), it is not easy to see avulsed osseous in adults due to complete ossification. The avulsed fragment can thus be easily seen in children because of incomplete ossification. Nonetheless, magnetic resonance imaging can also be used to evaluate the degree of tendon retraction and any damage around the bony structure. Meanwhile, there are several treatment options for Gamp that might restore his torn biceps femoris. Having been diagnosed a grade II biceps femoris tear, Gump can get back to his normal athletics activity after undergoing a physical therapy that would repair his partially torn hamstring. The physical therapy will be administered by a skilled professional who will use both manual therapy and therapeutic exercise to treat the pain. The manual therapy will include specific hands-on techniques that aim to reduce pain, treat the soft tissue restrictions, relax muscle guarding, cure the soft tissue inflammation, restore the muscle function and facilitate movement (Pickel & Swift, 2020). Ideally, the physical therapy treatment will involve stretching. Here, Gump will lie on his side while supporting his lower leg with his knee and his flex. The patient’s leg will then be held and brought into abduction (Takahashi et al, 2017) and while at that position, the physician will try to support his body against Gump’s body so that the patient can extend the knee while pressing the knee into flexion. With the other hand, the physician will hold the client’s upper leg and with the thenar of his other hand, the physician will try to stretch the muscle away from the site of insertion. According to Takahashi et al (2017), most grade II non-operative treatments recover well after a timely repair. However, it is important to note that there are no specific guidelines that dictate when the injury should be treated surgically. However, several studies (e.g. Kayani et al, 2020, Ayoub et al, 2020) indicate that a complete repair of biceps femoris tendon can be achieved through surgery. When Gump has recovered from the injury and he is considering returning his normal athletics activities, it is important to conduct some functional assessments such as an assessment for the absence of tenderness, hamstring power, assessment of passive and active hip flexion. In conclusion, biceps femoris tear is a common injury that is characterised by dysfunction and chronic inflammation of the tendon as a result of overuse or over-activation. Whereas it is a commonly misdiagnosed injury among many runners, a proper diagnosis and treatment can cause recovery and have the athlete back to their normal athletic activities. when a patient presents with such an injury, the first test is to conduct a general observation of the hamstring through palpation, in search of any pain or tenderness around the hamstring muscle. The other important tests for biceps femoris tear are hamstring flexibility, which would reveal some pain in case the patient is severely injured. The last test is that of hamstring strength, which the patient reported some pain during a leg curl. These results indicated that the patient had and biceps femoris tear and was lined up for therapy treatment. The recommended physical therapy will involve stretching of the muscle away from the site of insertion as well as other therapies that would repair his partially torn hamstring.

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