Acute Proximal Posterior Thigh Pain in a Division 1 Women’s Soccer Player

Abstract

HISTORY: A 22-year-old female soccer player for a Division 1 College team with a previous history of contralateral hamstring injury a year ago presents to the training room with acute onset left posterior thigh pain. She was seen in the training room 5 days prior with an ache in the posterior thigh. Sideline ultrasound was unremarkable for any abnormality at that time. Pain worsened while performing a drill during practice so she presents for re-evaluation. PHYSICAL EXAMINATION: No obvious gait abnormalities. No ecchymosis over posterior thigh. Tender to palpation at left proximal semitendinosus muscle belly but no palpable defect noted. Resisted knee flexion/hamstring activation and reverse plank reproduced pain. Strength was full and symmetric and sensation intact in bilateral lower extremities. DIFFERENTIAL DIAGNOSIS: 1. Acute medial hamstring strain/tear 2. Proximal medial hamstring tendinitis 3. Ischial bursitis 4. Adductor strain TEST AND RESULTS: Limited training room ultrasound reveals separation in the layers of investing fascia of semitendinosus/biceps femoris interval with sonopalpation tenderness reproducing her concordant symptom at the proximal hamstring region. There were no signs of muscular injuries on ultrasound. FINAL WORKING DIAGNOSIS: Acute left proximal semitendinosus/biceps femoris fascia tear without sonographic evidence of muscle strain in a senior soccer player with 3 games left of her career. TREATMENT AND OUTCOMES: Using sonographic guidance, 4 cc of autologous conditioned plasma (ACP/PRP) was injected at the site of fascial abnormality. Patient remained prone for 5 minutes following the injection followed by application of ACE wrap for the next 2 hours and use of thigh compression until she was pain free. She was instructed to rest completely for 24 hours with a progressive rehabilitation program to return to play. At 6 days post procedure, she progressed to jogging and warm up exercises with minimal residual pain but was advised to continue to refrain from soccer. At 1-week post procedure she was completely pain free and was cleared to return to play in the game the following day. She then returned as a starter in the last game of the season, 11 days post injection, and even assisted a goal that led to her team’s win. She is now 22 days post injury and remains pain free.