Rupture of the ischial origin of the hamstring muscles

Hamstring Injuries: A Current Concepts Review: Evaluation, Nonoperative Treatment, and Surgical Decision Making

The purpose of this current concepts review is to highlight the evaluation and workup of hamstring injuries, nonoperative treatment options, and surgical decision-making based on patient presentation and injury patterns. Hamstring injuries, which are becoming increasingly recognized, affect professional and recreational athletes alike, commonly occurring after forceful eccentric contraction mechanisms. Injuries occur in the proximal tendon at the ischial tuberosity, in the muscle belly substance, or in the distal tendon insertion on the tibia or fibula. Patients may present with ecchymoses, pain, and weakness. Magnetic resonance imaging remains the gold standard for diagnosis and may help guide treatment. Treatment is dictated by the specific tendon(s) injured, tear location, severity, and chronicity. Many hamstring injuries can be successfully managed with nonoperative measures such as activity modification and physical therapy; adjuncts such as platelet-rich plasma injections are currently being investigated. Operative treatment of proximal hamstring injuries, including endoscopic or open approaches, is traditionally reserved for 2-tendon injuries with >2 cm of retraction, 3-tendon injuries, or injuries that do not improve with 6 months of nonoperative management. Acute surgical treatment of proximal hamstring injuries tends to be favorable. Distal hamstring injuries may initially be managed nonoperatively, although biceps femoris injuries are frequently managed surgically, and return to sport may be faster for semitendinosus injuries treated acutely with excision or tendon stripping in high-level athletes.

Repair of Retracted Hamstring Tears with Hamstring Pulley Technique and Inferomedial Portal

Endoscopic repair of hamstring tears is well described in the literature, but endoscopic management for significantly retracted hamstring tears is not well described. Currently, repairing a hamstring tendon that has retracted 8 cm or more from the footprint on the ischial tuberosity is performed as an open procedure. The technique described here details endoscopic repair of retracted hamstring tears using a suture pulley mechanism and an inferomedial portal.

Systematic Review of Complications Associated With Proximal Hamstring Tendon Repair

Background

Although several complications of proximal hamstring tendon ruptures have been reported in the literature, few studies have comprehensively analyzed the complication profile of proximal hamstring tendon repair.

Purpose

To identify the overall rate of complications following proximal hamstring tendon repair and to differentiate these complications into categories.

Study Design

Systematic review; Level of evidence, 4.

Methods

Included in this review were studies that examined surgical repair of proximal hamstring tendon ruptures; all studies were in English and had an evidence level of 4 or higher. No restrictions were made regarding publication date or methodological quality. Data regarding complications were extracted to calculate the overall complication rate as well as the rate of major and minor complications. A quantitative data synthesis was conducted using the chi-square test to compare the proportion of patients who experienced complications with the endoscopic versus open approach.

Results

A total of 43 articles including 2833 proximal hamstring tendon repairs were identified. The overall postoperative complication rate was 15.3% (n = 433). The rate of major complications was 4.6%, including a 1.7% rate of sciatic nerve injury, 0.8% rate of venous thromboembolism, 0.8% reoperation rate, 0.8% rerupture rate, and 0.4% rate of deep infection. Minor complications included a 2.4% rate of posterior femoral cutaneous nerve injury, 2.3% rate of persistent hamstring myopathy, 2.2% rate of persistent sitting pain, 1.8% rate of peri-incisional numbness, 1.1% rate of superficial infection, and 0.8% rate of hematoma/seroma.

Conclusion

Proximal hamstring tendon repair is associated with an overall complication rate of 15.3%, including a 4.6% rate of major complications.

Degree of Tendon Retraction and Younger Age Are Associated With Functional Decline Following Nonoperative Management of Complete Proximal Hamstring Ruptures

Purpose

To characterize functional outcomes of patients with complete proximal hamstring tendon ruptures who were treated nonoperatively and determine whether there are patient characteristics associated with unfavorable outcomes.

Methods

We retrospectively identified patients aged 18-80 (treated 1/2000-12/2019) who received nonoperative management of complete rupture of the hamstring tendon origin. Participants completed the Lower Extremity Functional Scale (LEFS), as well as Tegner Activity Scale (TAS), and a chart review was conducted to obtain demographic and medical information. Preinjury and postinjury TAS scores were compared, and additional models quantified associations between LEFS scores or changes in TAS scores (ΔTAS) and patient characteristics.

Results

Twenty-eight subjects (mean age: 61.5 ± 1.5 years; 10 male) were included. The mean follow-up time was 5.8 ± 0.8 years (range: 2-22 years). Mean preinjury and postinjury TAS scores were 5.3 ± 0.4 and 3.7 ± 0.4, respectively, with a change of 1.5 ± 0.3 (P = .0002). Degree of tendon retraction showed a negative correlation with LEFS score (P = .003) and ΔTAS (P = .005). Increased follow-up time (P = .015) and body mass index (P = .018) were associated with lower LEFS scores. Moreover, increased follow-up time (P = .002) and younger age at injury (P = .035) were associated with more negative ΔTAS. Patients classified with an American Society of Anesthesiologists (ASA) score of 2 had a median LEFS score that was 20 points (95% CI: 6.9-33.6) lower than those classified as ASA 1 (P = .015).

Conclusions

In this study, we found that increased degree of tendon retraction, increased follow-up time, and younger age at initial injury were associated with significantly worse self-reported functional outcomes.

Level of Evidence

Level IV, prognostic case series.

Outcomes of Open and Endoscopic Repairs of Chronic Partial- and Full-Thickness Proximal Hamstring Tendon Tears: A Multicenter Study With Minimum 2-Year Follow-up

BACKGROUND

The preponderance of literature on the repair of proximal hamstring tendon tears focuses on the acute phase (<4 weeks). As such, there is a paucity of data reporting on the outcomes of chronic proximal hamstring tears.

PURPOSE

To report minimum 2-year postoperative patient-reported outcome (PRO) scores, visual analog scale (VAS) for pain, and patient satisfaction from patients who underwent open or endoscopic repair of partial- and full-thickness chronic proximal hamstring tendon tears.

STUDY DESIGN

Case series study; Level of evidence, 4.

METHODS

Between April 2002 and May 2017, prospectively collected data from 3 tertiary care institutions were retrospectively reviewed for patients who underwent open and endoscopic repair of partial- and full-thickness chronic proximal hamstring tendon tears. Patients were included only if they had a chronic proximal hamstring tear (defined as ≥4 weeks from symptom onset to surgery). Patients were excluded if they had a tear treated <4 weeks after injury, underwent hamstring reconstruction, or claimed workers' compensation. Patients who reported minimum 2-year follow-up for VAS, patient satisfaction, and the following PROs had their outcomes analyzed: the modified Hip Harris Score, Non-arthritic Hip Score, iHOT-12 (International Hip Outcome Tool), and Hip Outcome Score-Sports Specific Subscale.

RESULTS

Fifty patients (34 females and 16 males) were included in this study. There were 19 endoscopic repairs and 31 open repairs. Within the cohort, 52.0% had a full-thickness tendon tear on magnetic resonance imaging, and 48.0% had a partial tear. Average follow-up time was 58.07 ± 37.27 months (mean ± SD; range, 24-220 months). The mean age and body mass index of the group were 46.13 ± 13 years and 25.43 ± 5.14. The average time from injury to surgery was 66.73 weeks (range, 5.14-215.14 weeks). Average postoperative PROs were as follows: modified Hip Harris Score, 91.94 ± 9.96; Non-arthritic Hip Score, 91.33 ± 9.99; iHOT-12, 87.17 ± 17.54; Hip Outcome Score-Sports Specific Subscale, 87.15 ± 18.10; and VAS, 1.16 ± 1.92. Patient satisfaction was 8.22 ± 1.20.

CONCLUSION

Patients who underwent open and endoscopic repairs for chronic partial- and full-thickness proximal hamstring tendon tears reported high PROs and satisfaction at a minimum 2-year follow-up with low rates of complications.

Tears of Biceps Femoris, Semimembranosus, And Semitendinosus are Not Equal-A New Individual Muscle-Tendon Concept in Athletes

Objectives:

Hamstring injuries are common and can now be accurately diagnosed. In addition, novel surgical indications have been introduced. However, evidence-based guidelines on the hamstring injuries in management of top-level athletes are missing.

Methods:

The management methods and outcomes of treatment are classically based on relatively small case series. We discuss a novel concept based on the fact that each tendon of the hamstrings muscle should be managed in an individual fashion. Furthermore, suitable indications for hamstring surgery in athletes are introduced.

Results:

The present study introduces modern treatment principles for hamstring injury management. Typical clinical and imagining findings as well as surgical treatment are presented based on a critical review of the available literature and personal experience.

Conclusions:

Hamstring injuries should not be considered to be all equal given the complexity of this anatomical region: The three separate tendons are different, and this impacts greatly on the decision-making process and outcomes in athletes.

Proximal hamstring tendon avulsion: state of the art

Complete proximal hamstring tendon avulsions from the ischial tuberosity, though infrequent, are the most severe type of hamstring muscle injury in the field of sport medicine. These serious injuries are commonly associated with a delayed or even misdiagnosis, despite obvious clinical findings. The published literature favours surgical repair even though the studies represent lower levels of evidence. Non-surgical treatment is a viable option for lower physical demand patients. This state-of-the-art article reviews the relevant anatomy, the clinical assessment including specific physical examination signs and diagnostic testing in patients suspected of a proximal hamstring avulsion. Up-to-date evidence is reviewed to address surgical and non-surgical treatment options and outcome assessment. The authors provide a detailed description of what would be considered the current worldwide standard of care; an open, suture-anchor-based repair of the avulsed tendon complex (semitendinosus, long head of biceps femoris and semimembranosus) securely to the ischial tuberosity. Also included are surgical tips and tricks, with advice on postsurgical management and rehabilitation. Future perspectives should involve higher quality, prospective research to better define the indications for surgery, evaluate the emerging role of endoscopic repair and disclose complications along with measuring patient-reported outcomes.

Use of a Fascia Lata Autograft to Reconstruct a Large Triceps Tendon Defect After En-Bloc Resection of a Soft-Tissue Sarcoma: A Case Report

CASE

In this report, we present the case of a patient undergoing en-bloc resection of a large triceps soft-tissue sarcoma, requiring reconstruction of the triceps tendon including its distal insertion. We describe a surgical technique using fascia lata (FL) autograft to reconstruct the patient's extensor mechanism with long-term follow-up and functional results.

CONCLUSIONS

FL autograft is a viable option for reconstruction of large tendinous defects. It is simple and straightforward to harvest, inexpensive when compared with alternatives, with many potential applications.

Functional Results and Outcomes After Repair of Partial Proximal Hamstring Avulsions at Midterm Follow-up

BACKGROUND

Partial avulsions of the proximal hamstring origin remain a challenging problem with nonoperative treatments frequently providing limited success. The literature is limited regarding the outcomes of operative management in the active and athletic population.

HYPOTHESIS

Surgical fixation of proximal hamstring ruptures will have favorable outcomes at midterm follow-up.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

A total of 64 patients with partial avulsions of the proximal hamstring origin treated with surgical fixation by a single surgeon were reviewed at a 2-year minimum follow-up. All patients had initially undergone failed nonoperative treatment. Patient-reported outcome scores on the Lower Extremity Functional Score (LEFS), Marx Activity Rating Scale, custom LEFS and Marx scales, and total proximal hamstring score were evaluated. Data on patient-perceived strength, return to sport, and satisfaction were also collected.

RESULTS

The cohort included 27 male and 37 female (N = 64) patients with a mean age of 47.3 years (range, 16-65 years), and all were reviewed at a mean 6.5-year (range, 2-12.5 years) follow-up. The average postoperative LEFS was 96% (range, 68%-100%), with the custom LEFS being 90% (range, 39%-100%). The mean Marx score was 12.4 (range, 4-16). The Marx custom score demonstrated no disability with activities of daily living. The mean total proximal hamstring score was 94% (range, 69%-100%). No differences in any outcome measures were seen when comparing acute versus chronic repairs. Three patients underwent further hamstring surgery. No patients reported symptoms of numbness in the operative extremity at rest, while 3 patients had a superficial stitch abscess treated with antibiotics alone. The most commonly reported difficulty was with prolonged sitting. Ninety-seven percent were satisfied with surgery, 92% reported they could participate in strenuous activity, and 97% estimated their strength to be >75%, while 64% estimated it to be 100% of their contralateral side. Patients returned to sport at an average of 11.1 months, and all that returned were satisfied with their performance.

CONCLUSION

Both early and delayed anatomic surgical repair of partial proximal hamstring avulsions leads to successful functional outcomes, a high rate of return to athletic activity, and low complication rates at the 6.5-year follow-up. Nonoperative treatments should first be attempted.

Accelerated rehabilitation results in good outcomes following acute repair of proximal hamstring ruptures

PURPOSE

To assess outcomes of patients who underwent proximal hamstring repair utilizing an accelerated rehabilitation protocol with immediate weight bearing as tolerated and no bracing.

METHODS

Retrospective chart review identified 47 proximal hamstring tendon repairs with suture anchors in 43 patients performed during 2008-2015. Rehabilitation included no immobilization or limited weightbearing. Patients were contacted by phone to assess outcomes utilizing the lower extremity functional score (LEFS), single-assessment numeric evaluation (SANE), and Marx activity scale. Overall patient-reported scores were calculated and results of acute and chronic repairs compared.

RESULTS

Thirty-four patients (38 repairs, 80.8%) were available for follow-up at mean of 4.1 ± 2.0 years following repair. There were two re-tears: one complete rupture 5 weeks postoperative and one partial rupture 10 weeks postoperative in the chronic group. Patients in general reported low pain and good function with a mean LEFS score of 87 ± 21%, a mean SANE score of 88.1 ± 11.6, and a mean numeric pain score of 8.5 ± 15.3 in the last week and 12.2 ± 21.1 with activity. The acute repair group was noted to have a higher mean LEFS score (93.7 versus 79.8%, p = 0.004) and SANE score (91.3 versus 83.8, p = 0.047), and lower pain with activity (21.7 versus 4.8, p < 0.001) as compared to the chronic group.

CONCLUSIONS

Repair of acute proximal hamstring ruptures results in good function and pain relief with the use of a rehabilitation protocol that does not require weight-bearing restrictions or bracing.

LEVEL OF EVIDENCE

III, therapeutic.

Reconstruction of chronic proximal hamstring avulsion injuries using ipsilateral distal hamstring tendons results in good clinical outcomes and patient satisfaction

PURPOSE

To report outcomes following proximal hamstring reconstruction employing an ipsilateral distal hamstring tendon autograft, in patients with chronic proximal ruptures.

METHODS

Six patients presenting with a chronic proximal hamstring avulsion and a medial time from injury of 11.0 months (range 7-18), confirmed via magnetic resonance imaging, underwent proximal hamstring repair using a free graft harvested from the ipsilateral distal hamstrings. Patients were evaluated at 6, 12 and 24 months post-surgery, via the Perth Hamstring Assessment Tool, the Short Form Health Survey, the Lower Extremity Functional Scale, a Patient Satisfaction Questionnaire, the Active Knee Extension and 6 min walk tests, the single and triple hop tests for distance, and isokinetic knee extensor and flexor strength. Knee strength was assessed at 180° and 240°/s (total work, peak and average torque), and both mean absolute scores and limb symmetry indices (LSIs) comparing the operated and non-operated limbs were presented.

RESULTS

Patients demonstrated good clinical improvement throughout the post-operative timeline in all subjective and objective outcomes. Mean knee extensor LSIs had recovered by 12 and 24 months. At 24 months post-surgery, while mean LSIs for knee flexor peak and average torque were at (or above) 90%, a significant difference still existed between the operated and non-operated limbs in knee flexor total work. At 24 months, five patients (83%) were satisfied with the results of the surgery, as well as their ability to return to recreational and sporting activities. There were two adverse events including an early deep vein thrombosis and a secondary surgery to remove a loosened staple.

CONCLUSIONS

While isokinetic hamstring strength had not fully recovered by 24 months, this surgical technique demonstrated a high level of patient satisfaction and return to function, in patients with chronic proximal hamstring ruptures. As the clinical relevance, this surgical technique provides a viable option with good post-operative outcomes for patients with chronic proximal hamstring tears that cannot be approximated back to the ischium.

LEVEL OF EVIDENCE

IV.

Proximal Hamstring Injuries: Management of Tendinopathy and Avulsion Injuries

PURPOSE OF REVIEW

To outline the typical presentation, physical examination, diagnostic imaging, and therapeutic treatment options for proximal hamstring injuries to improve awareness, expedient diagnosis, and definitive management.

RECENT FINDINGS

Proximal hamstring tendinopathy and partial-thickness tears can often successfully be managed with a combination of non-operative modalities, including physiotherapy focused on eccentric strengthening, extracorporeal shock wave therapy, or peri-tendinous injections. Surgery is reserved for refractory cases, but can yield good outcomes. Contrastingly, non-operative treatment often leads to unsatisfactory outcomes in complete ruptures, with residual weakness and reduced function with poor return-to-sport rates. Instead, surgical repair can provide satisfactory outcomes, with good-to-excellent functional outcomes and strength, with acute treatment preferred over delayed, chronic repair. Hamstring tendinopathy and partial-thickness tears can be successfully treated non-operatively with good functional outcomes, with surgical repair reserved for refractory cases. Complete tears are best managed with surgical repair, allowing improved strength and functional outcomes.

Predictors of Clinical Outcomes After Proximal Hamstring Repair

Background

Proximal hamstring avulsions cause considerable morbidity. Operative repair results in improved pain, function, and patient satisfaction; however, outcomes remain variable.

Purpose

To evaluate the predictors of clinical outcomes after proximal hamstring repair.

Study Design

Case series; Level of evidence, 4.

Methods

We retrospectively reviewed proximal hamstring avulsions repaired between January 2014 and June 2017 with at least 1-year follow-up. Independent variables included patient demographics, medical comorbidities, tear characteristics, and repair technique. Primary outcome measures were the Single Assessment Numerical Evaluation (SANE), International Hip Outcome Tool-12 (iHOT-12), and Kerlan-Jobe Orthopaedic Clinic (KJOC) Athletic Hip score. Secondary outcome measures included satisfaction, visual analog scale for pain, Tegner score, and timing of return to sports.

Results

Of 102 proximal hamstring repairs, 86 were eligible, 58 were enrolled and analyzed (67%), and patient-reported outcomes were available for 45 (52%), with a mean 29-month follow-up. The mean patient age was 51 years, and 57% were female. Acute tears accounted for 66%; 78% were complete avulsions. Open repair was performed on 90%. Overall satisfaction was 94%, although runners were less satisfied compared with other athletes (P = .029). A majority of patients (88%) returned to sports by 7.6 months, on average, with 72% returning at the same level. Runners returned at 6.3 months, on average, but to the same level 50% of the time and at a decreased number of miles per week compared to nonrunners (15.7 vs 7.8, respectively; P < .001). Postoperatively, 78% had good/excellent SANE Activity scores, but the mean Tegner score decreased (from 5.5 to 5.1). Acute tears had higher SANE Activity scores. The mean iHOT-12 and KJOC scores were 99 and 77, respectively. Endoscopic repairs had equivalent outcome scores to open repairs, although conclusions were limited given the small number of patients in the endoscopic group. Greater satisfaction was noted in patients older than 50 years (P = .024), although they were less likely to return to running (P = .010).

Conclusion

Overall, patient satisfaction and functionality were high. With the numbers available, we were unable to detect any significant differences in functional outcome scores based on patient age, sex, body mass index, smoking status, medical comorbidities, tear grade, activity level, or open versus endoscopic technique. Acute tears had better SANE Activity scores. Runners should be cautioned that they may be unable to return to the same preinjury activity level after proximal hamstring repair.

Clinical Relevance

When counseling patients with proximal hamstring tears, runners and those with chronic tears should set appropriate expectations.

Endoscopic Proximal Hamstring Repair and Ischial Bursectomy Using Modified Portal Placement and Patient Positioning

Endoscopic management has become an effective method to repair proximal hamstring injuries. However, due to the complexity of such a procedure, the dissemination of the technique of endoscopic hamstring repair has occurred slowly among orthopaedic surgeons. This Technical Note with a video modifies previously described techniques and provides safer and more simplified endoscopic management of proximal hamstring injuries.

Outcomes After Operative and Nonoperative Treatment of Proximal Hamstring Avulsions: A Systematic Review and Meta-analysis

BACKGROUND

No meta-analysis has compared outcomes of operative and nonoperative proximal hamstring avulsion treatment.

PURPOSE

To compare outcomes of operative and nonoperative proximal hamstring avulsion treatment, including acute, chronic, partial, and complete repairs.

STUDY DESIGN

Meta-analysis.

METHODS

PubMed, CINAHL, SPORTdiscus, Cochrane Library, EMBASE, and Web of Science were searched up to July 2016. Three authors screened the studies and performed quality assessment using criteria from the Methodologic Index for Nonrandomized Studies. A best evidence synthesis was subsequently used.

RESULTS

Twenty-four studies (795 proximal hamstring avulsions) were included. Twenty-two studies included proximal hamstring avulsion repairs; 1 study had proximal hamstring avulsion repairs and a control group of nonoperatively treated proximal hamstring avulsions; and 1 study had solely nonoperatively treated proximal hamstring avulsions. The majority of studies were of low methodological quality. Overall, repairs had significantly higher patient satisfaction (90.81% vs 52.94%), hamstring strength (85.01% vs 63.95%), Lower Extremity Functional Scale scores (72.77 vs 69.53), and single-legged hop test results (119.1 vs 56.62 cm) (all P < .001); complications occurred in 23.17% of cases. Compared with chronic repairs, acute avulsion repairs had greater patient satisfaction (95.48% vs 83.79%), less pain (1.07 vs 3.71), and greater strength (85.2% vs 82.8%), as well as better scores for the Lower Extremity Functional Scale (75.64 vs 71.5), UCLA activity scale (University of California, Los Angeles; 8.57 vs 8.10), and Single Assessment Numeric Evaluation (93.36 vs 86.50) (all P < .001). Compared with partial avulsion repairs, complete avulsion repairs had higher patient satisfaction (89.64% vs 81.35%, P < .001), less pain (1.87 vs 4.60, P < .001), and higher return to sport or preinjury activity level, but this was insignificant (81.43% vs 73.83%, P = .082). Partial avulsion repairs had better hamstring strength (86.04% vs 83.71%, P < .001) and endurance (107.13% vs 100.17%, P < .001). Complete repairs had significantly higher complication rates (29.38% vs 11.27%, P = .001).

CONCLUSION

Proximal hamstring avulsion repair resulted in superior outcomes as compared with nonoperative treatment, although the complication rate was 23.17%. The nonoperative group was quite small, making a true comparison difficult. Acute repairs have better outcomes than do chronic repairs. Complete avulsion repairs had higher patient satisfaction, less pain, and a higher complication rate than partial avulsion repairs, although partial avulsion repairs had better hamstring strength and endurance. Studies of high methodological quality are lacking in terms of investigating the outcomes of proximal hamstring avulsion repairs.

Narrative review of injuries in powerlifting with special reference to their association to the squat, bench press and deadlift

Pain and injuries are considered a common problem among elite athletes and recreational lifters performing the squat, bench press and deadlift. Since all three lifts engage multiple joints and expose the lifters’ bodies to high physical demands often several times a week, it has been suggested that their injuries might be related to the excessively heavy loads, the large range of motion during the exercises, insufficient resting times between training sessions and/or faulty lifting technique. However, no previous article has summarised what is known about specific injuries and the injury aetiology associated with the three lifts. Thus, the aim of this narrative review was to summarise what is known about the relationships between the powerlifting exercises and the specific injuries or movement impairments that are common among lifters and recreationally active individuals.

Central Tendon Injuries of Hamstring Muscles: Case Series of Operative Treatment

Background:

As compared with injuries involving muscle only, those involving the central hamstring tendon have a worse prognosis. Limited information is available regarding the surgical treatment of central tendon injuries of the hamstrings.

Purpose:

To describe the operative treatment and outcomes of central tendon injuries of the hamstrings among athletes.

Study Design:

Case series; Level of evidence, 4.

Methods:

Eight athletes (6 top level, 2 recreational) with central hamstring tendon injuries underwent magnetic resonance imaging and surgical treatment. The indication for surgery was recurrent (n = 6) or acute (n = 2) central hamstring tendon injury. All patients followed the same postoperative rehabilitation protocol, and return to play was monitored.

Results:

Magnetic resonance imaging found a central tendon injury in all 3 hamstring muscles (long head of the biceps femoris, semimembranosus, and semitendinosus) with disrupted tendon ends. In acute and recurrent central tendon injuries, full return to play was achieved at 2.5 to 4 months. There were no adverse events during follow-up.

Conclusion:

Central tendon injuries of the hamstrings can be successfully repaired surgically after acute and recurrent ruptures.

Proximal hamstring tendon avulsion surgery: evaluation of the Perth Hamstring Assessment Tool

PURPOSE

The purpose of the present study was to validate a new scoring system for proximal hamstring injury-the Perth Hamstring Assessment Tool (PHAT).

METHODS

This is a prospective series of 74 consecutive proximal hamstring surgical repairs in 72 patients, with a median age of 50.5 years (range 16-74). Patients completed the PHAT, SF12 Health Survey and Lower Extremity Functional Scale (LEFS). The scoring system was validated by calculating its internal consistency, reproducibility, reliability and sensitivity to change. Construct validity was evaluated using Pearson's correlation analysis to examine the strength of association between the PHAT, LEFS and SF-12 scores.

RESULTS

The PHAT showed high completion rate (100 %), high internal consistency (Cronbach's alpha 0.80), high reproducibility (ICC 0.84) and high sensitivity to change. There was moderate correlation with the LEFS and low correlation with the Physical Component Score of the SF-12.

CONCLUSION

This study has validated the PHAT as an assessment tool for proximal hamstring tendon injuries. The new questionnaire provides a measure of outcome that is reliable and sensitive to clinically important change. This simple questionnaire provides the clinician with a quick and practical tool for assessing patients with proximal hamstring injuries: to assess pre-operative disability and monitor recovery post-operatively.

LEVEL OF EVIDENCE

II.

A prospective evaluation of proximal hamstring tendon avulsions: improved functional outcomes following surgical repair

PURPOSE

Avulsion of the proximal hamstring tendons is an uncommon injury. To date, few studies have prospectively evaluated outcomes of surgical repair. The aim of the present study is to review the functional outcomes of surgical repair of proximal hamstring tendon avulsions.

METHODS

This is a prospective series of 96 consecutive proximal hamstring surgical repairs in 94 patients, with a median age of 50 years and median follow-up of 33 months (range 12-58). Functional outcomes were assessed using the Perth Hamstring Assessment Tool (PHAT)-a validated scoring system for proximal hamstring injuries.

RESULTS

Significant improvements in functional outcomes were seen across all patients at 1-year follow-up. There was a mean PHAT score improvement of 34.7 points at the 1-year follow-up (p < 0.001, 95% CI 29.9-39.5). The SF-12 PCS scores showed a significant improvement at 1-year follow-up of 13.8 points (p < 0.001, 95% CI 10.7-16.9). These were maintained at final follow-up. Acute repairs had significantly higher improvement in PHAT score with acute patients improving a mean of 38.6 points (p < 0.001, 95% CI 32.0-44.3) and chronic patients only improving by a mean of 25.3 points (p < 0.001, 95% CI 18.2-33.3) at final follow-up.

CONCLUSION

This study establishes that surgical repair of proximal hamstring tendon ruptures leads to improved patient outcomes, in both acute and chronic repairs. Early surgical repair, however, achieves superior outcomes to late repair. These results suggest that surgeons should be operating on proximal hamstring avulsions, and preferably in the acute stage.

LEVEL OF EVIDENCE

II.

[Proximal rupture of the hamstring tendon : From clinical presentation to diagnosis and therapy]

Rupture of the proximal tendon enthesis of the hamstring muscle (ICM) accounts for approximately 10% of all injuries of the ICM. It occurs most commonly in athletes and active middle-aged individuals. The complete rupture of all three tendons in active patients is generally seen as an indication for surgical repair of the tendon enthesis; however, the correct diagnosis is often not reached in a timely manner. This can lead to prolonged symptoms with pain, weakness and neuralgia. Operative treatment consists of anchor repair of the tendons resulting in good clinical outcome in several case series. Good knowledge of the anatomy and operative approach are mandatory to avoid complications as well as compliance with a gradual rehabilitation scheme to allow tendon to bone healing. The main aim of this review is to highlight the typical history, clinical presentation and examination technique to reach an immediate clinical diagnosis which should be confirmed with a magnetic resonance imaging (MRI) scan.

Athletic injuries

Injuries are common in the various disciplines that make up the sport of athletics. Diagnosis depends on an accurate history and competent examination, possibly assisted by imaging techniques such as ultrasound, magnetic resolution imaging and computerized tomography. It is also important to consider the influence of various intrinsic and extrinsic factors in deciding on the mechanism of injury. Most acute injuries relate to overstretching of soft tissue, whereas overuse injuries reflect repetitive microtrauma with degenerative or inflammatory consequences. Steroid injections should be restricted to situations where inflammation predominates. Surgery may be required for specific acute injuries and when supervised rehabilitation over 6 months fails to resolve chronic injury. Following surgery, physical and psychological rehabilitation should be carefully planned.

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.

Anatomy of the Adductor Magnus Origin: Implications for Proximal Hamstring Injuries

Background:

The adductor magnus (AM) has historically been a potential source of confusion in patients with suspected proximal hamstring avulsion injuries.

Purpose:

To investigate the anatomic characteristics of the AM, including its osseous origin, anatomic dimensions, and relationship to the proximal hamstring tendons.

Study Design:

Descriptive laboratory study.

Methods:

Dissection of the AM origin was performed in 11 (8 cadavers) fresh-frozen hip-to-foot cadaveric hemipelvis specimens. The gross anatomy and architecture of the proximal hamstring and AM tendons were studied. After dissecting the hamstring tendons away from their origin, the dimension, shape, and orientation of the tendon footprints on the ischial tuberosity were determined.

Results:

The AM was identified in all cadaveric specimens. The mean tendon thickness (anterior to posterior [AP]) was 5.7 ± 2.9 mm. The mean tendon width (medial to lateral [ML]) was 7.1 ± 2.2 mm. The mean tendon length was 13.1 ± 8.7 cm. The mean footprint height (AP dimension) was 12.1 ± 2.9 mm, and mean footprint width (ML dimension) was 17.3 ± 7.1 mm. The mean distance between the AM footprint and the most medial aspect of the conjoint tendon footprint was 8.5 ± 4.2 mm. Tendon measurements demonstrated a considerable degree of both intra- and interspecimen variability.

Conclusion:

The AM tendon is consistently present just medial to the conjoint tendon at the ischial tuberosity, representing the lateral-most portion of the AM muscle. This study found wide variation in the dimensional characteristics of the AM tendon between specimens. Its shape and location can mimic the appearance of an intact hamstring (conjoint or semimembranosus) tendon intraoperatively or on diagnostic imaging, potentially misleading surgeons and radiologists. Therefore, detailed knowledge of the AM tendon anatomy, footprint anatomy, and its relationship to the hamstring muscle complex is paramount when planning surgical approach and technique.

Clinical Relevance:

The reported data may aid surgeons in more accurate recognition, diagnosis, and repair of proximal hamstring avulsion injuries.

Anatomic Description of the Origin of the Proximal Hamstring

PURPOSE

To define the topographic anatomy of the footprint of the hamstrings origin on the ischium.

METHODS

Dissection of the hamstrings origin in 6 cadaveric pelvises was performed. The hamstrings origin was isolated with sharp dissection, and it was noted whether the semimembranosus had a separate attachment or whether there was one confluent tendon attached at the footprint. The common hamstrings tendon was then sharply dissected from the ischium, and the footprint was outlined with surgical marker followed by radiopaque paint. Paint was prepared by mixing 0.25 g Daler-Rowney acrylic artists ink scarlet no. 567 (Daler-Rowney, Bracknell, England) per gram of EZ-HD 98% v/w barium sulfate (E-Z-EM Inc, Lake Success, NY). The paint was then applied to the area of the footprint, and the specimen underwent a 0.5-mm-slice computed tomographic (CT) scan of the pelvis with 3-dimensional (3D) reconstructions. Vitrea (Vital Images, Minnetonka, MN) software was used to determine the surface area of the ligament footprint as well as the distance from the ischial tuberosity to the center of the footprint. The thickness of the bone underlying the footprint was measured. Data are presented as means ± standard error.

RESULTS

Five of 6 specimens had a common hamstrings tendon, whereas one had a separate attachment for the semimembranosus. The semimembranosus joined the common hamstrings tendon 2.33 ± 0.61 cm distal to the footprint. The average surface area of the hamstrings footprint measured 10.19 ± 0.75 cm(2). The distance from the tip of the ischial tuberosity to the center of the hamstrings footprint measured 3.73 ± 0.22 cm. The average thickness of the bone deep to the footprint was 3.77 ± 0.9 cm.

CONCLUSIONS

This study provides a topographic description of the origin of the hamstrings footprint and may assist surgeons in performing anatomic reattachment of this tendon.

CLINICAL RELEVANCE

Our data will assist surgeons in performing anatomic repair of proximal hamstrings avulsions.

Reattachment of the proximal hamstring origin: outcome in patients with partial and complete tears

PURPOSE

To assess the subjective and functional outcome in complete and partial injuries, both acute and chronic.

METHODS

One hundred and thirty-two consecutive proximal hamstring reattachments were performed by a single surgeon between 1999 and 2009. The mean age at the time of operation was 42.5 years (SD 12.2), the mean duration of follow-up was 53.8 months (SD 19.5), and all patients with a minimum 2-year follow-up were included in the study. Patients were reviewed independently. Functional outcome was evaluated using quantitative assessments of pre-operative and postoperative hamstring strength and endurance, while subjective outcome was undertaken at the latest follow-up using a three-tier questionnaire.

RESULTS

The most common cause of injury was waterskiing (29 patients). There were 96 complete injuries and 36 partial injuries. Overall, 112 of 132 patients rated their result as good/excellent, 91 had returned to their pre-injury level of sporting activity, and 114 said that they would undergo surgery again. Mean postoperative hamstring strength was 83 %, and mean hamstring endurance was 108 % compared to the contralateral limb. Patients with complete injuries and those operated and those operated on acutely (<6 weeks) were more likely to have a good/excellent result. There was no significant correlation between time to repair, type of injury (partial vs. complete) and functional outcome.

CONCLUSION

Good to excellent results can be expected in the majority of patients, following surgical reattachment. Surgery is well tolerated with the vast majority of patients, reporting that they would undergo surgery again.

LEVEL OF EVIDENCE

IV.

Hamstring injuries

There is a continuum of hamstring injuries that can range from musculotendinous strains to avulsion injuries. Although the proximal hamstring complex has a strong bony attachment on the ischial tuberosity, hamstring injuries are common in athletic population and can affect all levels of athletes. Nonoperative treatment is mostly recommended in the setting of low-grade partial tears and insertional tendinosis. However, failure of nonoperative treatment of partial tears may benefit from surgical debridement and repair. The technique presented on this article allows for the endoscopic management of proximal hamstring tears and chronic ischial bursitis, which until now has been managed exclusively with much larger open approaches. The procedure allows for complete exposure of the posterior aspect of the hip in a safe, minimally invasive fashion.

Surgical excision of posttraumatic ossifications at the proximal hamstrings in young athletes: technique and outcomes

BACKGROUND

Proximal hamstring tears can be associated with chronic disability related to the unusual formation of heterotopic ossifications. The role for operative intervention in these circumstances has not been clearly defined.

PURPOSE/HYPOTHESIS

The purpose of this study was to describe the surgical management of young athletes who had chronic disability related to proximal hamstring ossifications after eccentric load injuries. The hypothesis was that after surgical excision of posttraumatic heterotopic ossifications at the proximal hamstrings with concomitant repair of the tendons to the ischium, significant functional improvement with low risk of postoperative complications can be expected at minimum 2-year follow-up.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

The cases of 11 consecutive male athletes who developed chronic disability associated with heterotopic ossifications at the proximal hamstring muscles after sports-related tears were reviewed. During surgery, the ossified mass was meticulously excised, and the tendons were debrided and fixed to the ischium. At minimum 2-year follow-up, self-reported outcome was rated as excellent, good, moderate, or poor. Operative reports and office visits were reviewed. Activity level before the injury and at latest follow-up was graded with the Tegner scale.

RESULTS

The median age at injury was 17 years (range, 13-25 years). Sports activities included ice hockey, soccer, track and field athletics, and judo. Mean interval from injury to surgery was 45 months. The smallest ossified mass was 2 × 2 × 4 cm and the largest, 3 × 4 × 9 cm. Median follow-up was 4 years (range, 2-10 years). Six patients had excellent, 1 patient had good, and 4 patients had moderate outcomes; 7 of them were able to return to preinjury activities (Tegner score, 7-10). There were 2 cases of loss of skin sensation at the posterior femoral cutaneous nerve distribution, but neither patient described this as significantly interfering with any activity. All patients had symmetric side-to-side single-legged hop test and a 5 out of 5 on hamstring muscle strength at latest follow-up.

CONCLUSION

Heterotopic ossifications that develop at the proximal hamstrings after eccentric load injuries can be associated with significant chronic disability. These cases can be effectively treated by surgical excision of the ossified masses and concomitant debridement with suture fixation of the proximal hamstring tendons to the ischium. Return to preinjury activities is expected in the majority of these cases, with low postoperative risks.

Complete Avulsion of the Proximal Hamstring Insertion: Functional Outcomes After Nonsurgical Treatment

BACKGROUND

Complete proximal hamstring avulsions are an uncommon injury. The purpose of this study was to determine the functional and subjective outcomes following nonsurgical management of complete proximal hamstring avulsions.

METHODS

We retrospectively identified nineteen patients (mean age, fifty-nine years; range, forty-four to seventy-three years) at one institution who presented with complete avulsions of the proximal hamstring insertion, confirmed on magnetic resonance imaging, and had nonsurgical treatment. Results on the Lower Extremity Functional Scale (LEFS) and Short Form-12 version 2 (SF-12v2) questionnaires as well as functional and isometric testing (with a handheld dynamometer) were collected. Seventeen patients completed the questionnaires. Ten patients underwent functional testing. The average follow-up period was thirty-one months (range, eight to 156 months).

RESULTS

The mean score on the LEFS was 70.2 of a maximum of 80 points. The mean SF-12v2 physical and mental component summary scores were 52.5 and 54.1, respectively. Hamstring strength at 45° and 90° of flexion was an average of 62% (p = 0.09) and 66% (p = 0.07), respectively, of that of the uninvolved limb. The single-leg hop test revealed an average decline of 2.2% (p = 0.93) compared with the uninvolved limb. Twelve of the seventeen patients were able to return to their previous sporting activities.

CONCLUSIONS

Nonsurgical management after a complete proximal hamstring avulsion yields noticeable subjective and strength deficits.

LEVEL OF EVIDENCE

Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Functional Outcomes and Return to Sports After Acute Repair, Chronic Repair, and Allograft Reconstruction for Proximal Hamstring Ruptures

BACKGROUND

There are limited data regarding outcomes and return to sports after surgery for acute versus chronic proximal hamstring ruptures.

HYPOTHESIS

Surgery for chronic proximal hamstring ruptures leads to improved outcomes and return to sports but at a lower level than with acute repair. Proximal hamstring reconstruction with an Achilles allograft for chronic ruptures is successful when direct repair is not possible.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

Between 2002 and 2012, a total of 72 patients with a traumatic proximal hamstring rupture (51 acute, 21 chronic) underwent either direct tendon repair with suture anchors (n = 58) or Achilles allograft tendon reconstruction (n = 14). Results from the Single Assessment Numeric Evaluation (SANE) for activities of daily living (ADL) and sports-related activities, Short Form-12 (SF-12), visual analog scale (VAS), and a patient satisfaction questionnaire were obtained.

RESULTS

The mean time to surgery in the chronic group was 441.4 days versus 17.8 days in the acute group. At a mean follow-up of 45 months, patients with chronic tears had inferior sports activity scores (70.2% vs 80.3%, respectively; P = .026) and a trend for decreased ADL scores (86.5% vs 93.3%, respectively; P = .085) compared with those with acute tears. Patients with chronic tears, however, reported significant improvements postoperatively for both sports activity scores (30.3% to 70.2%; P < .01) and ADL scores (56.1% to 86.5%; P < .01). Greater than 5 to 6 cm of retraction in the chronic group was predictive of the need for allograft reconstruction (P = .015) and resulted in ADL and sports activity scores equal to those of chronic repair (P = .507 and P = .904, respectively). There were no significant differences between groups in SF-12, VAS, or patient satisfaction outcomes (mean, 85.2% satisfaction overall).

CONCLUSION

Acute repair was superior to chronic surgery with regard to return to sports. Acute and chronic proximal hamstring repair and allograft reconstruction had favorable results for ADL. For low-demand patients or those with medical comorbidities, delayed repair or reconstruction might be considered with an expected 87% return to normal ADL. For patients who desire to return to sports, acute repair is recommended.

Sacrotuberous ligament: relationship to normal, torn, and retracted hamstring tendons on MR images

PURPOSE

To evaluate continuity of the sacrotuberous ligament (STL) in normal and abnormal hamstring (HS) tendons on magnetic resonance (MR) images and to test the hypothesis that greater degrees of HS retraction are correlated with STL discontinuity.

MATERIALS AND METHODS

The institutional review board approved this retrospective HIPAA-compliant study and waived informed consent. Control cohort comprised 33 patients (mean age, 54.1 years) without HS abnormalities at hip MR arthrography. Study cohort comprised 100 patients (mean age, 55.3 years) with HS abnormalities at pelvic or hip MR imaging. Two musculoskeletal radiologists independently assessed STL continuity with the ischium and semimembranosus (SM) and conjoined biceps femoris and semitendinosus (BF-ST) tendons and evaluated these tendons for tendinopathy, partial tear, or rupture. A third musculoskeletal radiologist measured retraction of ruptured tendons. Inter- and intraobserver agreement was calculated with weighted κ or intraclass correlation coefficients. HS abnormalities in the cohorts were compared with Mann-Whitney test. In patients with tendon rupture, relationships between qualitative (STL and HS attachments) and quantitative (tendon retraction measurements) data were analyzed with analysis of variance and linear regression with Bonferroni correction.

RESULTS

STL was continuous with ischium in all patients. In control patients, STL was always continuous with BF-ST but never continuous with SM. In study patients, BF-ST tendon alone, SM tendon alone, and both BF-ST and SM tendons showed abnormalities in 17, six, and 77 patients, respectively. HS rupture occurred in 24 patients; it involved BF-ST tendon alone in 13 patients and both BF-ST and SM tendons in 11. STL was continuous with BF-ST tendon in 12 patients and discontinuous in 12 patients. Retraction of BF-ST tendon (mean, 33 mm; range, 5-81 mm) was independently correlated with STL continuity with BF-ST (P = .0001) and SM (P = .0004) tendon rupture. Retraction was significantly greater (P ≤ 0.01) when STL was discontinuous and SM tendon was ruptured. Inter- and intraobserver agreement was very good or excellent in categorization of HS abnormalities and measurement of retraction.

CONCLUSION

STL showed continuity with both ischium and BF-ST tendon but not SM tendon. In HS rupture, tendon retraction was significantly less when STL remained attached to BF-ST tendon.

Partial rupture of the hamstring muscle complex: a literature review on treatment options

Injuries of the hamstring muscle complex (HMC) often affect athletes participating in specific sporting activities. Mild injuries that constitute a mere strain of the muscle can be managed symptomatically, while severe injuries often require surgical intervention to precipitate a return to function. Neglected injuries usually result in a long-term functional impairment. Therefore, surgical reconstruction of the HMC is advised for both partial and complete lesions. Without acute repair, a chronic lesion referred to as hamstring syndrome can result due to dysfunction of the HMC. Surgical intervention is usually recommended. A case of a chronic severe partial injury to the HMC managed conservatively in a 49-year old female is presented to illustrate the level of function that can be achieved after non-operative management. The clinical and radiological findings are presented 18 months post-injury along with a review of the current literature. There are no previous reports in the literature describing this scenario. This case indicates the need for re-evaluation in treatment options in partial hamstring muscle ruptures. A surgical treatment of partial rupture should be considered more often as an adequate treatment option and cofactors that influence the prognosis must be revealed. The indication of surgical intervention should be re-evaluated within the first months in case of conservative treatment.

Returning to sports after surgical repair of acute proximal hamstring ruptures

PURPOSE

Although the treatment of choice for acute proximal hamstring ruptures is now surgical repair, this technique is relatively new and requires further evaluation. Our hypothesis was that patients return to sports at the same level after surgical repair as before injury.

METHODS

From 2002 to 2011, a prospective observational study including 34 patients, mean age 39.3 ± 11.4 years old underwent surgical repair of an acute proximal hamstring rupture. Surgical, rehabilitation and follow-up protocols were standardized. Mean follow-up was 27.2 ± 22.9 months and there were no lost to follow-up. The primary outcome was the level of activity on the UCLA and Tegner scores.

RESULTS

The mean UCLA score was 9.1 ± 1.3 before injury and 8.7 ± 1.7 at the final follow-up (p = 0.03). The median Tegner activity level was 6 (range, 4-10) before injury and 6 (range, 3-10) at the final follow-up (p = 0.05). The two scores were correlated (r = 0.76, p = 0.00001). Patients returned to sports within a mean 5.7 ± 1.6 months, at the same level in 27 patients (79.4 %) and at a lower level in 7 patients (20.6 %). The average hamstring/quadriceps ratio at 240°/second was 54.7 ± 8.6 % which was positively correlated to the level of activity on the UCLA score (r = 0.49, n.s.). The level of satisfaction was related to their level of activity at the final follow-up (p = 0.03).

CONCLUSION

Although surgical repair of acute proximal hamstring ruptures has significantly improved the functional prognosis of patients it remains a serious condition that can compromise future sports activities.

LEVEL OF EVIDENCE

Case-control study, Level III.

Total proximal hamstring ruptures: clinical and MRI aspects including guidelines for postoperative rehabilitation

The aim of this article is to provide a state-of-the-art review for treatment of acute, total proximal hamstring tendon ruptures. For total proximal hamstring tendon ruptures, early (<2-3 w) surgical refixation minimizes muscle atrophy and facilitates a somewhat predictable time course for healing and rehabilitation. A postoperative rehabilitation program is detailed that has been used by one physical therapist for the past 7 years on over 200 patients with surgical repair for total proximal hamstring tendon rupture. One re-rupture has occurred, 7 months after surgery, following the rehabilitation program described herein. The rehabilitation program, including avoidance of postoperative bracing, appears effective for total proximal hamstring ruptures. Early surgery together with a specific rehabilitation program appears to be the treatment of choice for timely and safe return to sport and an active lifestyle. Level of evidence V.

Endoscopic proximal hamstring repair and ischial bursectomy

With the significant increase in use of the arthroscope around the hip have come several less invasive techniques to manage pathologies around this joint. This technical note with a video details one such technique that allows for the endoscopic management of proximal hamstring tears and chronic ischial bursitis, which until now have been managed exclusively with much larger open approaches. This procedure allows for complete exposure of the posterior aspect of the hip in a safe, minimally invasive fashion.

Clinical and magnetic resonance imaging outcomes after surgical repair of complete proximal hamstring ruptures: does the tendon heal?

BACKGROUND

The use of validated outcome questionnaires and magnetic resonance imaging (MRI) when assessing outcomes after surgical treatment of proximal hamstring avulsions has been limited.

PURPOSE

To comprehensively evaluate clinical, functional, and radiological outcomes in patients treated with surgical repair for complete proximal hamstring avulsions.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

A retrospective review of 15 consecutive patients was performed. Outcome measures included the Single Assessment Numeric Evaluation (SANE), visual analog scale (VAS) for pain, Proximal Hamstring Injury Questionnaire, Lower Extremity Functional Scale (LEFS), Harris Hip Score (HHS), and Tegner Activity Scale (TAS). Physical examination was performed by an independent sports medicine fellow. Magnetic resonance imaging of the lower extremity was used to assess tendon healing and muscle quality after repair.

RESULTS

Thirteen of 15 (87%) eligible patients were available for follow-up at a mean 36.9 months (range, 27-63 months), including 8 men and 6 left-sided injuries. The average age was 44.6 years (range, 26-58 years). Twelve of 13 patients underwent surgical repair within 60 days of injury. Mean (± standard deviation) postoperative functional outcome scores were as follows: LEFS, 74.9 ± 7.8 (range, 59-80); HHS, 90.7 ± 13.9 (range, 67-100); SANE, 93.6 ± 7.5 (range, 75-100); VAS for pain, 1.3 ± 1.9 (range, 0-5); and TAS, 4.6 ± 2.3 (range, 1-7). All 11 patients who participated in sports before surgery were able to return to sport, but 45% reported a decrease in their current level of activity. Isokinetic muscle testing demonstrated that injured hamstring strength recovered up to 78% ± 6.1% (range, 74%-88%) of the contralateral side. The MRI examinations revealed that 100% of patients had a healed proximal hamstring repair, with signs of tendinopathy and mild atrophy in 3 of 12 patients.

CONCLUSION

The current findings indicate that surgical repair of complete hamstring ruptures provides reliable pain relief, good functional outcomes, high satisfaction rates, and excellent healing rates (MRI) but does not fully restore hamstring function and sports activity to preinjury levels.

Posterior hip pain in an athletic population: differential diagnosis and treatment options

Context:

Posterior hip pain is a relatively uncommon but increasingly recognized complaint in the orthopaedic community. Patient complaints and presentations are often vague or nonspecific, making diagnosis and subsequent treatment decisions difficult. The purposes of this article are to review the anatomy and pathophysiology related to posterior hip pain in the athletic patient population.

Evidence Acquisition:

Data were collected through a thorough review of the literature via a MEDLINE search of all relevant articles between 1980 and 2010.

Results:

Many patients who complain of posterior hip pain actually have pain referred from another part of the body—notably, the lumbar spine or sacroiliac joint. Treatment options for posterior hip pain are typically nonoperative; however, surgery is warranted in some cases.

Conclusions:

Recent advancements in the understanding of hip anatomy, pathophysiology, and treatment options have enabled physicians to better diagnosis athletic hip injuries and select patients for appropriate treatment.

Proximal hamstring avulsion injuries: a technique note on surgical repairs

Proximal hamstring avulsions from the ischium are becoming more frequently recognized, secondary to their disability when treated nonoperatively. The acute repair of these injuries is becoming prevalent given the improved outcomes reported in the literature. Anatomic studies have recently been conducted on the proximal hamstring origin; however, there are few reports on surgical techniques for repair in the setting of injury. The present article describes the technique for proximal hamstring avulsion repair, as performed by the senior author. More than 30 cases have been performed based on this technique, with excellent results.

Functional results and outcomes after repair of proximal hamstring avulsions

BACKGROUND

The purpose of this study was to assess postsurgical outcomes in active patients after primary repair of acute and chronic proximal hamstring tears.

HYPOTHESIS

Surgical treatment of both acute and chronic proximal hamstring avulsion injuries would result in improved patient outcomes using validated outcome scores and a hamstring-specific questionnaire, and operative repair of these injuries results in excellent outcomes with a high level of patient satisfaction, pain relief, and return to function.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

Fifty-two patients who underwent proximal hamstring repair (26 male and 26 female; average age, 47.7 years) completed the Lower Extremity Functional Scale (LEFS), a custom LEFS, the Marx Activity Scale, a custom Marx scale, a proximal hamstring score (which combines the sum of the custom LEFS and Marx), and a proximal hamstring questionnaire with subjective questions. Forty patients were characterized as having acute repairs, and 12 patients had chronic repairs. All patients underwent surgical repair with 5 suture anchors on the ischial tuberosity through a transverse incision. The rehabilitation protocol was also similar with the use of a hip orthosis for 6 to 8 weeks, allowing progressive weightbearing and range of motion.

RESULTS

The mean follow-up in our study was 33 months (range, 12-76 months). The mechanism of injury in 28 patients was eccentric hip flexion and knee extension in the ipsilateral knee typically caused by a slip and fall accident. One patient's injury was caused by trauma to the proximal hamstring. In 23 patients, hamstring injuries were sports related. Overall, 51 (98%) were satisfied with their outcome after surgery. The LEFS, Marx, custom LEFS, custom Marx, and proximal hamstring scores for patients with acute injuries were 76.2, 10.0, 71.4, 20, and 91.7, respectively. For those with chronic injury, the scores were 71.5, 10.4, 70.8, 18.7, and 89.8, respectively. The scores were not statistically different for LEFS, Marx, custom LEFS, and proximal hamstring scores (P = .22, P = .6, P = .72, and P = .6, respectively). Patients with acute injury did have a greater custom Marx score (P = .001). Postoperatively, 5 patients (9.6%) had burning pain or numbness in the posterior thigh or foot, and 25 (48%) had at least some discomfort sitting. Thirty-five patients (67%) reported they could participate in strenuous activities at their latest follow-up. All patients estimated their strength recovery at ≥75%.

CONCLUSION

Results of this study indicate successful outcomes for both acute and chronic repairs, although patients with the acute repairs had higher functional and hamstring scores, and estimated hamstring strength.

Mechanisms of proximal hamstring rupture in a non-athlete healthy middle-aged female

PURPOSE

To present an explicatory pathophysiological model for the rare clinical case of a total proximal hamstring rupture for the first time in the literature.

METHODS

A non-athletic healthy female (49 years) experienced a complete rupture of the right conjoint tendon of the biceps femoris (long head) and semitendinosus muscle while slipping down a lawn-covered slope (eccentric hip flexion and knee extension during stance phase of gait after heel-strike). A hamstring rupture was diagnosed by clinical examination and confirmed by magnet resonance imaging (MRI). Surgical reattachment of the conjoint tendon to the ischial tuberosity was performed. One year after surgery, she experienced no pain or functional impairment.

RESULTS

Histological analysis and immune-histochemical staining (vascular endothelial growth factor - receptor 2) of a biopsy taken intra-operatively revealed signs of fibroblast proliferation and vasculoneogenesis with absence of inflammatory changes indicating that repairing mechanisms and tissue remodeling had been taking place.

CONCLUSION

This case report provides evidence for the hypothesis that micro-injuries induce repairing mechanisms and thus tissue remodeling which leads to consecutive tissue weakening and mechanical failure during a non-adequate trauma. Micro-injuries can occur during leisure activities and remain clinically invisible until rupture.

Functional outcome after repair of proximal hamstring avulsions

BACKGROUND

Rupture of the proximal origin of the hamstrings leads to pain, weakness, and a debilitating decrease in physical activity. Repair of these injuries should be based on the expectation that these deficits can be addressed. The goal of this study was to objectively evaluate the efficacy of repair of proximal hamstring avulsions.

METHODS

Thirty-four patients were identified retrospectively to have a complete rupture of the proximal origin of the hamstrings based on the presence of a bowstring sign and the results of magnetic resonance imaging (MRI).Patients were contacted for follow-up evaluation to fill out a subjective questionnaire, to undergo functional testing, and to undergo isokinetic testing on a Cybex dynamometer. Twenty-three patients were evaluated.

RESULTS

There were nine acute and fourteen chronic repairs, and the average period of follow-up was 43.3 months. Twenty-one of twenty-three patients reported returning to activity at an average of 95% of their pre-injury activity level at an average of 9.8 months. Eighteen patients reported excellent results; four, good results; and one, fair results. Hamstring strength was an average of 93% and 90% of that in the uninvolved limb at 240° per second and 180° per second, respectively. The hamstrings-to-quadriceps ratio was 56% for 240° per second and 48% at 180° per second. Hamstring endurance was an average of 81% and 91% of the nonoperative limb at 240° per second and 180° per second, respectively. Postoperative quadriceps strength and endurance were positively correlated with return to pre-injury level of activity (r = 0.6, p < 0.05; and r = 0.6, p < 0.05) and negatively correlated with time to return to sport (r = -0.5, p < 0.05; and r = -0.5, p < 0.05). There was no significant effect associated with age or time from injury.

CONCLUSIONS

Repair of a symptomatic and displaced ruptured proximal hamstring tendon yields good subjective and objective functional results with minimal complications. Overall, patients are satisfied with surgical repair and experience return of functional activity with minimal postoperative weakness.

Early surgical repair of acute complete rupture of the proximal hamstring tendons

Hamstring injuries are common forms of muscle strains in athletes but a complete rupture of a proximal hamstring origin is rare. Often there is a considerable delay in diagnosis and stringent treatment because of its rarity, difficulty in clinical diagnosis, and initial attempts of conservative care. We report two cases of acute complete rupture of the proximal hamstring tendons treated with early surgical repair. The diagnosis and treatment of this unusual injury are discussed.

Popliteal soft tissue tumor associated with hamstring injury

We report herein a very rare case of semitendinosus tear that formed a tumor in the popliteal region after not having recovered as a result of only being instructed to rest. The soft tissue tumor was discovered on ultrasonography 4 months after pain and sensation of discomfort appeared in the popliteal region. We considered this symptom as dependent on the presence of the tumor and selected surgical treatment. Intraoperatively, this soft tissue tumor was connected with the pes anserinus by tendinous tissue. On pathological examination, the soft tissue tumor was diagnosed as skeletal muscle showing necrosis. From imaging, operative findings, and pathological diagnosis, this was considered to represent a rare case in which myorrhexis developed into a soft tissue tumor in the popliteal region after a semitendinosus tear remained unhealed and was neglected over the long term. Although we had trouble confirming a diagnosis and treatment procedure, we were able to acquire good results with surgical treatment. This is, to the best of our knowledge, the first report of damaged semitendinosus becoming a soft tissue tumor in the popliteal region after long-term neglect without healing.