Here is mine and Rebecca Tidmarsh’s poster presentation for STYD02, on An 18 year-old gymnast diagnosed with RED-S and camping of posterior thigh pain.
An 18-year old gymnast diagnosed with RED-S complaining
Script
Lauren
Introduction:
This patient, an 18-year-old female gymnast who has currently been suffering with posterior thigh pain has been recently diagnosed with Relative Energy Deficiency (RED-S). Through her current sport (gymnastics) we can assume that she as a substantial amount of training during the weeks at a very high intensity/level as well, also having schoolwork on top of that can be quite stressful.
Lauren
Mechanisms of Injury
This client came in c/o a pain in the posterior thigh region, this client has had this pain for the last 3 days. This pain was a sudden onset, with no referred pain. This client thinks the injury has occurred from over-using the muscles as she is competing in Nationals, so this client is training 5-6/7 a week so putting a lot of strain on these muscles. Also, gymnastics is a very demanding sport on the body, so this has a massive impact on the body and muscles. This injury may have occurred from lack of vitamins and the correct food and this could be from the client being diagnosed with RED-S.
Becks
Red Flags and Contraindications
There are numerous Red flags and contraindications that you have to be wary of and find out about during the subjective assessment this includes some of the main Red flags and contraindications including THREADS and medication that the client could be on. There are also Yellow flags that you have to be wary of when treating a client these are any psychosocial barriers that could be stopping them from recovering, this includes her emotions and attitudes towards the injury, sport and rehabilitation.
As the client has RED-S this is a red flag, you also have to make sure you are aware of what part of the syndrome is affecting the athlete but also checking the other components that are linked with RED-S. This can include loss of menstruation, any weight changes, this can link to the clients eating habits making sure to note if they have any eating disorders, or recent changes in their eating habit. As well as, the amount of exercise they are doing, as the clients “dietary energy intake is insufficient to support the energy expenditure required for health, function and daily living, once the cost of exercise and sporting activities is taken into account.”(Mountjoy et al., 2015)As a practitioner you have to be very cautious when a client has RED-S as there are different effects on performance both in and out of sport.
Lauren
Relative Energy Deficiency:
Relative Energy Deficiency, also known as RED-S is a syndrome that an affect men and women, this syndrome refers to impairment in, although impaired but not limited to, physical function including the metabolic rate, menstrual function (female) bone health, immunity, protein synthesis and cardiovascular health. Females can also be further affected due to the Athlete Triad. This can involve an irregular menstrual cycle, bone health and an eating disorder.
As a therapist, I have to be really cautious when treating this client has not only has she got RED-S, the athlete triad can also affect her injury even more. I will also have to be aware that because she has weaker bones in her body, I need to be cautious that she hasn’t fractured anything in her body, especially when it comes to assessing the patient. I also need to be aware of energy levels as I don’t know how much she consumes as she is currently in training and is also still learning in school. I have to be careful as this can affect the muscles in the body, and this can make them weaker. This can impact her having lower energy levels means this can slow down co-ordination and then she can have a higher risk of injury.
Due to her age, she is also taking the contraceptive pill. This prevents pregnancy and this can also be used to help with the menstrual cycle. The contraceptive pill can be used to stop period all together, make periods more regular and to keep a regular cycle. There are loads of different types of contraceptive pills and people use different ones. This is due to having issues with the pill as this could be down to levels of oestrogen so they can be moved into another pill to what suits them better.
Females that compete at a high level, like this client, may take the contraceptive pill to reduce period symptoms and stop the menstrual cycle as they have very intense training and don’t want symptoms to stop them from training. As a therapist, we need to be aware if the client is on the contraceptive pill as this can have an impact on recovery as they won’t recover as effectively. The contraceptive pill can also cause soft tissue to become softer and more pliable, again then affecting recovery. This then means the muscles become even more weaker (laxer) and then can lead to more injuries.
Becks
Possible Diagnosis
These are the differential diagnosis that the client could have from feeling pain in the posterior part of their thigh. They are split into common, less common and diagnosis that cannot be missed by practitioners.
For common diagnosis is hamstring muscle strains, these usually occur when the muscle fibres tear depending on the severity of the tear and the type/grade of strain (Lempainen, Banke, Johansson, & Imhoff, 2014)(Belk et al., 2019), there are three types of strains.
Type I is an acute hamstring strain mainly involving the bicep femoris, that can usually occur when the hamstring is performing high intensity exercise such as, over loading such as when an individual is sprinting, hurdling, jumping or kicking. There is minimal tissue damage to the hamstring therefore has minimal inflammation, pain on contraction and stretch, with both local pain and tenderness. (Kornberg, Sc, Grad, & Man, 1989)
Type II strains are also acute and mean that the semimembranosus is usually involved. Type II strains means that there is a partial tear but not all of the muscle fibres are broken (Mendiguchia, Alentorn-geli, & Brughelli, 2012). The individual will be able to see a noticeable loss of strength and function in the leg hindering their ability to complete everyday activities without being in pain such as walking (Lempainen et al., 2014).
Type III or reoccurring strains are when there is a total tear or rupture of the hamstring muscle or the muscle will come away from the bone (Lempainen et al., 2014). This type of strain will show a lot of swelling and the patient will complain loss of strength and function as they will struggle to put weight onto the injured leg.
Individuals could also have a hamstring contusion or “dead leg” which can occur after a direct impact to the hamstrings. Contusions can also be graded depending on the severity of the injury (Kujala, Orava, & Jiirvinen, 1997). They could also feel posterior thigh pain from gluteal trigger points as well can also be referred pain from the lumbar spine.
Less common diagnosis for posterior thigh pain include referred pain from the sacroiliac joint. Hamstring tendinopathy is an overuse injury that causes the tendons to inflame and cause individuals’ pain, this mainly happens in the proximal end of the hamstrings (Jayaseelan, 2014). Semimembranosus and Ischiogluteal bursitis is where the bursa can become inflamed that could in rare cases rupture due to trauma (Beltran et al., 2003)(Swartout & Compere, 1974). Hamstring syndrome is another uncommon diagnosis as it caused by a build up of pressure on the nerve, between the pelvis and hamstring tissue causing pain in the hip and numbness down the back of the thigh (Belk et al., 2019). Lastly is an avulsion fracture of the ischial tuberosity, this usually occurs in younger athletes and is where the tendons from any hamstring muscle could break a part of the bone off where they attach (Liu et al., 2018)(Harris, Griesser, Best, & Ellis, 2011).
When assessing an individual with posterior thigh pain practitioners have got to be careful not to miss any tumours especially bone tumours in the patient and an iliac artery endofibrosis where the iliac artery is thickened causing there to be a restricted blood flow to the patients lower extremities(Collaborators et al., 2016).
Becks
Clinical Assessment
An 18 year old female client came in to the clinic complaining of posterior thigh pain that eases throughout the day and feels tight in the morning after waking up. She has been diagnosed with RED-S and has visible bruising down the back of her thigh.
They have iced their hamstrings which has eased the pain as well as taking NSAIDs and resting their leg as completing exercise aggravates the pain that they feel.
The client first felt pain at training when they tried to complete a run up in a floor routine before having to pull up in their sprint after feeling a popping sensation. They rested their leg before trying to continue with training. However, the pain was too great for them to carry on.
The client discussed how she has a national competition coming up and has been put under pressure by her parents and coaches to do well and increase her training. They will also be worried about how she would exercise with her injury wanting to keep her weight under control.
In observations the client had a slight limp when walking with visible deformities in the right leg including swelling and bruising. When palpating the leg the client felt the most pain along the semimembranosus.
In Active, passive and resisted range of motion the clients left leg was positive in all movements at the joint. Their right leg however they felt pain whilst actively trying to complete knee flexion, hip extension and internal rotation. Passively their was no feedback of pain in all movements and in resisted movement the client complained of pain in knee flexion and hip extension.
The client completed multiple special tests including, the bent-knee stretch and straight leg raise with all comping back positive apart from when completing the hip quadrant.
Lauren
Treatment:
Before any treatment, it’s important to be aware of the client being diagnosed with RED-S, as this causes laxity to muscles, making sure that she is getting treated for RED-S alongside her posterior thigh pain by medically trained staff.
As we are treating the injury in its acute phase, sudden onset. A sudden onset hamstring strain can also be known as an intrinsic injury. The most common treatment for this particular injury is isometric movement and cryotherapy. Isometric movements are done the acute phases as this treatment it used for strengthening muscles, and because this treatment doesn’t go through full of movement it won’t cause the patient even more pain which is good. This treatment allows the muscles to contract without moving the full range of movement making it more bearable to the client as this will really help with recovery. After a few sessions of using this treatment, we can then take the next step in the treatment by introducing concentric and eccentric movements.
When looking at isometric movements, its important to look at the antagonist muscles groups, in this case it would be the quadriceps. This is good for contracting muscles in the resisted movements, this is also good, and this treatment isolates the hamstrings meaning we can work other muscles without affecting the hamstrings and causing more pain. To get the best result from this treatment is to have the client led in the supine position on the plinth, face down having their knee flexed at 90 degrees and then asking the client to extent their leg actively.
Cryotherapy is also another really affective treatment that can be used this client. This helps to reduce inflammation on the affected area. In this case, the worse the grade of tear the worse the inflammation will be. Ice will decrease the swelling to the area, this can then allow the therapist to have another look at the client and perform more special tests. The therapists can further palpate as before the pain and swelling was too bad so we couldn’t get a clear reading. A good protocol to use is P.O.L.I.C.E, protection, optimal loading, ice, compression and elevation. There are numerous ways to use cryotherapy, ice pack, ice bath, game ready and the higher end cryotherapy option is a cryotherapy chamber.
Becks
Conclusion
In conclusion we believe that our client, the 18-year-old gymnast has a grade II hamstring strain of the semimembranosus muscle. This is because of the sport they play and how it includes making explosive movements causing the hamstring to strain. The client can have help with their RED-S by seeing different health professionals that are trained to help clients in the different aspects of RED-S that could affect their gymnastics.
Lauren
Here are our references