Hamstring avulsion injuries

Hamstring Injuries: A Paradigm for Return to Play

Muscle injuries are the most common sports-related injuries, with hamstring involvement most common in professional athletes. These injuries can lead to significant time lost from play and have a high risk of reinjury. We review the anatomy, mechanisms of injury, diagnostic imaging modalities, and treatment techniques for hamstring injuries. We also present the latest evidence related to return to play (RTP) after hamstring injuries, including a review of articles targeted to RTP in European soccer (Union of European Football Associations), American football (National Football League), and other professional sports. Review of imaging findings in hamstring injury, grading systems for injuries, considerations for RTP, as well as advances in injury prevention, are discussed.

Return to Sport After Surgical Management of Proximal Hamstring Avulsions: A Systematic Review and Meta-analysis

OBJECTIVE

To assess the rates and timing of return to sport for the surgical management of proximal hamstring avulsions (PHAs).

METHODS

Three databases, PubMed, MEDLINE, and EMBASE, were searched from database inception until October 7, 2017, by 2 reviewers independently and in duplicate. The inclusion criteria were studies reporting return to sport outcomes for surgical management of acute, chronic, complete, and partial PHA. The rate of return to sports was combined in a meta-analysis of proportions using a random-effects model.

RESULTS

Overall, 21 studies with a total of 846 patients met the inclusion criteria, with a mean age of 41.4 years (range, 14-71 years) and a mean follow-up of 37.8 months (range, 6-76 months). Two studies were of prospective comparative design (level II), 2 were retrospective comparative (level III), 8 were prospective case series (level IV), and 9 were retrospective case series (level IV). The overall mean time to return to sport was 5.8 months (range, 1-36 months). The pooled rate of return to any sport participation was 87% [95% confidence interval (CI), 77%-95%]. The pooled rate of return to preinjury level of sport was 77% (95% CI, 66%-86%).

CONCLUSIONS

Pooled results suggest a high rate of return to sport after surgical management of PHA; however, this was associated with a lower preinjury level of sport. No major differences in return to sport were found between partial versus complete and acute versus chronic PHA.

Patterns of Hamstring Muscle Tears in the General Population: A Systematic Review

Background

Hamstring tears are well recognised in the sporting population. Little is known about these injuries in the general population.

Purpose

Evaluating the rates, patterns and risk factors of non-sporting hamstring tears, compared to sporting related hamstring tears.

Data Sources

MEDLINE, EMBASE, CINAHL, and the Cochrane Central Register of Controlled Trials (1989–2015).

Study Selection

Studies reporting patients with a grade 2 or 3 hamstring muscle tear, identified clinically, confirmed by MRI imaging or direct visualisation during surgical exploration.

Data Synthesis

144 sets of linked data were extracted for analysis. Most injuries were in males (81.3%), where mean age at injury was lower (30.2, 95% CI 29.1–31.3) than in females (35.4, 95% CI 32.4–38.4) p = 0.06. Key differences were found in the proportion of non-sporting injuries in patients under and over the age 40 (p = 0.001). The proportion of non-sporting injuries was significantly higher in females compared to males (25.9% female non-sporting injuries, versus 8.5% male; p = 0.02). Avulsions were more frequently reported in non-sporting activities (70.5%). The proportion of such injuries was notably higher in females, though this failed to meet significance (p = 0.124). Grouped by age category a bimodal distribution was noted, with the proportion of avulsions greater in younger (age <15) and older patients (age > 40) (p = 0.008). 86.8% of patients returned to pre-injury activity levels with a similar frequency across all study variables; age, activity (sporting vs non-sporting) and injury type (avulsion vs tear).

Conclusion

This review highlights a proportion of adults suffering grade 2 or 3 hamstring injuries from activities other than the classic sports trauma. The majority of these non-sporting injuries were avulsion injuries that clustered in older female and skeletally immature patients suggesting a potential link to bone mineral density.

Nerve Wrapping of the Sciatic Nerve With Acellular Dermal Matrix in Chronic Complete Proximal Hamstring Ruptures and Ischial Apophyseal Avulsion Fractures

BACKGROUND

Patients with chronic injuries of the proximal hamstring can develop significant impairment because of weakness of the hamstring muscles, sciatic nerve compression from scar formation, or myositis ossificans.

PURPOSE

To describe the surgical outcomes of patients with chronic injury of the proximal hamstrings who were treated with hamstring repair and sciatic neurolysis supplemented with nerve wrapping with acellular dermal matrix.

STUDY DESIGN

Retrospective case series; Level of evidence, 4.

METHODS

Fifteen consecutive patients with a diagnosis of chronic complete proximal hamstring rupture or chronic ischial tuberosity apophyseal avulsion fracture (mean age, 39.67 years; range, 14-69 years) were treated with proximal hamstring repair and sciatic neurolysis supplemented with nerve wrapping with acellular dermal matrix. Nine patients had preoperative sciatica, and 6 did not. Retrospective chart review recorded clinical outcomes measured by the degree of pain relief, the rate of return to activities, and associated postoperative complications.

RESULTS

All 15 patients were followed in the postoperative period for an average of 16.6 months. Postoperatively, there were 4 cases of transient sciatic nerve neurapraxia. Four patients (26%) required postoperative betamethasone sodium phosphate (Celestone Soluspan) injectable suspension USP 6 mg/mL. Among the 9 patients with preoperative sciatica, 6 (66%) had a good or excellent outcome and were able to return to their respective activities/sports; 3 (33%) had persistent chronic pain. One of these had persistent sciatic neuropathy that required 2 surgical reexplorations and scar excision after development of recurrent extraneural scar formation. Among the 6 without preoperative sciatica, 100% had a good or excellent outcomes and 83% returned to their respective activities/sports. Better outcomes were observed in younger patients, as the 3 cases of persistent chronic sciatic pain were in patients older than 45 years.

CONCLUSION

This study suggests that when used as an adjunct to sciatic neurolysis, nerve wrapping with acellular dermal matrix can be a safe and effective method of treating younger patients with and preventing the development of sciatic neuropathic pain after chronic injury of the proximal hamstrings.

The hamstring muscle complex

PURPOSE

The anatomical appearance of the hamstring muscle complex was studied to provide hypotheses for the hamstring injury pattern and to provide reference values of origin dimensions, muscle length, tendon length, musculotendinous junction (MTJ) length as well as width and length of a tendinous inscription in the semitendinosus muscle known as the raphe.

METHODS

Fifty-six hamstring muscle groups were dissected in prone position from 29 human cadaveric specimens with a median age of 71.5 (range 45-98).

RESULTS

Data pertaining to origin dimensions, muscle length, tendon length, MTJ length and length as well as width of the raphe were collected. Besides these data, we also encountered interesting findings that might lead to a better understanding of the hamstring injury pattern. These include overlapping proximal and distal tendons of both the long head of the biceps femoris muscle and the semimembranosus muscle (SM), a twist in the proximal SM tendon and a tendinous inscription (raphe) in the semitendinosus muscle present in 96 % of specimens.

CONCLUSION

No obvious hypothesis can be provided purely based on either muscle length, tendon length or MTJ length. However, it is possible that overlapping proximal and distal tendons as well as muscle architecture leading to a resultant force not in line with the tendon predispose to muscle injury, whereas the presence of a raphe might plays a role in protecting the muscle against gross injury. Apart from these architectural characteristics that may contribute to a better understanding of the hamstring injury pattern, the provided reference values complement current knowledge on surgically relevant hamstring anatomy.

LEVEL OF EVIDENCE

IV.

Self-reported and performance-based functional outcomes after surgical repair of proximal hamstring avulsions

BACKGROUND

Because a proximal hamstring avulsion results in residual loss of function, surgical repair is recommended. Few studies have investigated postoperative function with validated outcomes.

PURPOSE

To examine lower extremity function after surgical repair of proximal hamstring avulsions using validated self-reported and performance-based functional outcomes.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

Operative records from 2006 to 2010 were retrospectively reviewed in 3 hospitals. A total of 39 patients who had undergone surgical repair of a proximal hamstring avulsion were identified, and 36 met the inclusion criteria. Thirty-one patients completed questionnaires with demographic background data and quality of life-related questions: the Lower Extremity Functional Scale (LEFS) and the Proximal Hamstring Injury Questionnaire (PHIQ). Thirty patients were evaluated using a Biodex dynamometer for isokinetic quadriceps and hamstring strength measurements at a velocity of 60 deg/s, and 27 patients performed 4 single-legged hop tests.

RESULTS

Twenty-eight repairs were acute (<4 weeks), and 3 were chronic. There were complete ruptures of all 3 tendons in 17 (55%) cases. The mean follow-up was 30 months. Most patients experienced little or no pain or limitations during activities of daily living. The mean LEFS score was 89%, and 29 (94%) of the 31 patients were satisfied with the result after surgery. Eighteen (58%) of the 31 patients had returned to their preinjury activity level. Significant differences in the mean hamstring strength (peak torque) (P < .001) and single-legged hop test (P = .01) between the uninvolved and involved leg were found. Twenty-two (71%) of the 31 patients did not fully trust their operated leg during physical activities and feared sustaining a hamstring injury. Return to activity significantly correlated with the single-legged hop test, the LEFS score, and the questions regarding trust and fear.

CONCLUSION

In this study, using both validated self-reported and performance-based outcome measures after surgical repair of proximal hamstring avulsions, minor pain and limitations to activities of daily living were seen. Isokinetic hamstring strength in the operated leg was significantly lower compared with the nonoperated leg, and a majority of the patients did not trust the operated leg completely during physical activity.

Avulsion of the proximal hamstring origin

BACKGROUND

The torn hamstring is a common athletic injury. The purpose of the present study was to review the clinical presentation of this injury, the diagnostic imaging findings, the surgical technique of reattachment, and the likely clinical outcome of surgery for the treatment of avulsion of the proximal hamstring origin.

METHODS

Seventy-two consecutive reconstructions in seventy-one patients with avulsion of the proximal hamstring origin were performed at a single center. The mean age at the time of the operation was 40.2 years. The mean duration of follow-up was twenty-four months, and all patients with a minimum duration of follow-up of six months were included. There were no exclusions. Patients were independently reviewed, and the mean postoperative isotonic hamstring strength was compared with that on the uninjured side.

RESULTS

Waterskiing was the most frequent cause of injury (twenty-one cases). The mean time between the injury and the operation was twelve months. The most common pathological finding was a complete avulsion of the proximal hamstring origin (sixty-three cases; 87.5%), with a mean retraction of 7 cm (range, 0 to 20 cm). The mean postoperative isotonic hamstring strength measured 84% (range, 43% to 122%) and the mean postoperative hamstring endurance measured 89% (range, 26% to 161%) when compared with the values on the contralateral side.

CONCLUSIONS

It is important to distinguish proximal hamstring origin avulsions (for which we recommend early surgical repair) from the majority of hamstring muscle injuries (which respond well to nonoperative treatment). The present study suggests that, in cases of complete avulsion with hamstring retraction, a delay in surgical repair renders the repair more technically challenging, may increase the likelihood of sciatic nerve involvement, increases the need for postoperative bracing, and reduces postoperative outcome in terms of hamstring strength and endurance. Once the nature of the injury has been established, the surgical treatment of hamstring origin avulsions has predictable and satisfactory results.

Surgical treatment of acute versus chronic complete proximal hamstring ruptures: results of a new allograft technique for chronic reconstructions

BACKGROUND

Acute surgical repair of proximal hamstring ruptures has been shown to result in a high return to preinjury activity level.

HYPOTHESIS

Achilles allograft reconstruction of chronic complete proximal hamstring ruptures results in improved function and strength that approaches that of acute surgical repairs.

STUDY DESIGN

Cohort study; Level of evidence, 2.

METHODS

Between 2002 and 2005, 26 patients underwent surgical treatment for complete proximal hamstring ruptures. Twenty-one were acute primary repairs. Five chronic ruptures were treated with Achilles allograft reconstruction with (n = 2) or without (n = 2) interference screw fixation or mobilization and primary repair (n = 1). Isokinetic strength testing was conducted postoperatively in 11 acute and 3 chronic cases, and a functional questionnaire was given at most recent follow-up.

RESULTS

Subjective results for all patients at a mean follow-up of 20 months revealed good leg control in 96%, no pain in 80%, and return to sporting activities in 76%. Ninety-six percent of patients said they would have the procedure done again. With the isokinetic testing available at most recent follow-up, there was no significant difference in the mean hamstring strength deficits for the acute versus chronic groups tested at 60 deg/s (8% vs 21%, P =.295) and 180 deg/s (12% vs 2%, P = .294). Overall, there were 3 major adverse events and 5 patients with superficial wound drainage treated with antibiotics.

CONCLUSION

Surgical treatment of acute and chronic complete proximal hamstring ruptures can result in a high return to full activity. Reconstruction of chronic ruptures with Achilles allograft appears to restore function and strength comparable to acute repairs.