Hamstring Injuries in the Athlete: Diagnosis, Treatment, and Return to Play

Hamstring Muscle Stiffness in Athletes with and without Anterior Cruciate Ligament Reconstruction History: A Retrospective Study

Introduction: Sports requiring sprinting, jumping, and kicking tasks frequently lead to hamstring strain injuries (HSI). One of the structural risk factors of HSI is the increased passive stiffness of the hamstrings. Anterior cruciate ligament (ACL) injury history is associated with a 70% increase in the incidence of HSI, according to a recent meta-analysis. The same report recommended that future research should concentrate on the relationships between the HSI risk factors. Hence, the present study aimed to retrospectively compare changes in the passive stiffness of the hamstrings in athletes with and without ACL reconstruction history. Methods: Using ultrasound-based shear-wave elastography, the mid-belly passive muscle stiffness values of the biceps femoris long head, semimembranosus, and semitendinosus muscles were assessed and compared amongst athletes with and without a history of ACL reconstruction. Results: There were no significant differences in the biceps femoris long head (injured leg (IL): 26.19 ± 5.28 KPa, uninjured contralateral (UL): 26.16 ± 7.41 KPa, control legs (CL): 27.64 ± 5.58 KPa; IL vs. UL: p = 1; IL vs. CL: p = 1; UL vs. CL: p = 1), semimembranosus (IL: 24.35 ± 5.58 KPa, UL: 24.65 ± 8.35 KPa, CL: 22.83 ± 5.67 KPa; IL vs. UL: p = 1; IL vs. CL: p = 1; UL vs. CL, p = 1), or semitendinosus (IL: 22.45 ± 7 KPa, UL: 25.52 ± 7 KPa, CL: 22.54 ± 4.4 KPa; IL vs. UL: p = 0.487; IL vs. CL: p = 1; UL vs. CL, p = 0.291) muscle stiffness values between groups. Conclusions: The passive mid-muscle belly stiffness values of the biceps femoris long head, semitendinosus, and semimembranosus muscles did not significantly differ between previously injured and uninjured athletes; therefore, further assessment for other muscle regions of hamstrings may be necessary. To collect more comprehensive data related to the structural changes that may occur following ACL reconstructions in athletes, a future study should examine the passive stiffness of wider muscle regions from origin to insertion.

The Categorization of Perinatal Derivatives for Orthopedic Applications

Musculoskeletal (MSK) pathology encompasses an array of conditions that can cause anything from mild discomfort to permanent injury. Their prevalence and impact on disability have sparked interest in more effective treatments, particularly within orthopedics. As a result, the human placenta has come into focus within regenerative medicine as a perinatal derivative (PnD). These biologics are sourced from components of the placenta, each possessing a unique composition of collagens, proteins, and factors believed to aid in healing and regeneration. This review aims to explore the current literature on PnD biologics and their potential benefits for treating various MSK pathologies. We delve into different types of PnDs and their healing effects on muscles, tendons, bones, cartilage, ligaments, and nerves. Our discussions highlight the crucial role of immune modulation in the healing process for each condition. PnDs have been observed to influence the balance between anti- and pro-inflammatory factors and, in some cases, act as biologic scaffolds for tissue growth. Additionally, we assess the range of PnDs available, while also addressing gaps in our understanding, particularly regarding biologic processing methods. Although certain PnD biologics have varying levels of support in orthopedic literature, further clinical investigations are necessary to fully evaluate their impact on human patients.

Acute and Chronic Effects of Static Stretching on Intramuscular Hamstring Stiffness

Passive hamstring stiffness varies proximo-distally, resulting in inhomogeneous tissue strain during stretching that may affect localized adaptations and risk of muscle injuries. The purpose of the present study was to determine the acute and chronic effects of static stretching (SS) on intramuscular hamstring stiffness. Thirty healthy active participants had acute changes in passive biceps femoris (BF), semimembranosus (SM), and semitendinosus (ST) stiffness measured at 25% (proximal), 50% (middle), and 75% (distal) muscle length, using shear-wave elastography, immediately after SS. Participants then completed 4 weeks of either a SS intervention (n = 15) or no intervention (CON, n = 15) with stiffness measured before and after the interventions. The acute and chronic effects of SS were compared between anatomical regions and between regions on the basis of their relative stiffness pre-intervention. Acutely, SS decreased stiffness throughout the BF and SM (p ≤ 0.05) but not the ST (p = 0.326). However, a regional effect of stretching was observed for SM and ST with greater reduction in stiffness occurring in stiffer muscular regions (p = 0.001-0.013). Chronically, SS increased BF and ST (p < 0.05), but not SM (p = 0.422) stiffness compared with CON, but no regional effect of stretching was observed in any muscle (p = 0.361-0.833). SS resulted in contrasting acute and chronic effects, acutely decreasing stiffness in stiffer regions while chronically increasing stiffness. These results indicate that the acute effects of SS vary along the muscle's length on the basis of the relative stiffness of the muscle and that acute changes in stiffness from SS are unrelated to chronic adaptations.

A Novel Minimally Invasive Surgically Induced Skeletal Muscle Injury Model in Sheep

Sports-related muscle injuries account for 10-55% of all injuries, which is a growing concern, especially given the aging world population. To evaluate the process of skeletal muscle injury and compare it with muscle lesions observed in humans, we developed a novel in vivo model in sheep. In this model, muscle injury was induced by an ultrasound-guided transverse biopsy at the myotendinous junction of the medial gastrocnemius muscle. Twelve male sheep were examined at 3, 7, 14, and 28 days post-injury. Histological, immunofluorescence, and MRI analyses indicate that our sheep model could resemble key human clinicopathological features. Statistically significant differences (p < 0.05) were observed in collagen I, dMHC, α-SMA, and CD68 immunohistochemical detection when comparing injured and healthy muscles. The injured gastrocnemius muscle exhibited elevated levels of type I collagen, infiltration of CD68(+) macrophages, angiogenesis, and the emergence of newly regenerated dMHC(+) myofibers, which persisted for up to 4 weeks post-injury. Similarly, the progression of muscle injury in the sheep model was assessed using advanced clinical 3 T MRI and compared with MRI scans from human patients. The data indicate that the sheep muscle injury model presents features similar to those observed in human skeletal muscle injuries. This makes it a valuable large animal model for studying muscle injuries and developing novel therapeutic strategies.

Current and future advances in practice: tendinopathies of the hip

Tendinopathy describes persistent tendon pain and loss of function related to mechanical loading. Two common hip tendinopathies seen in practice are gluteal tendinopathy and proximal hamstring tendinopathy. Both conditions can be frustrating for patients and clinicians due to the delay in diagnosis, significant disability caused and lack of response to common treatments. Tendinopathy is a clinical diagnosis and can most often be made using findings from the patient interview and pain provocation tests, without the need for imaging. Specific education and progressive exercise offer a low-risk and effective option for gluteal tendinopathy and result in greater rates of treatment success than corticosteroid injection, both in the short term (8 weeks) and at 1 year. Proximal hamstring tendinopathy is a common, but less researched, and under-recognized cause of persistent ischial pain. As research on proximal hamstring tendinopathy is limited, this review summarizes the available evidence on diagnosis and treatment following similar principles to other well-researched tendinopathies.

Medical ozone on hamstring injury in a professional athlete assessed by thermography: a clinical case report

Injuries associated with the hamstring muscles in the running athlete are increasingly investigated due to the economic and functional consequences associated with them. Although hardly used in the treatment of sports injuries, medical ozone is effective and very well tolerated in the treatment of musculoskeletal pain, it was decided to add a series of medical ozone infiltrations to the treatment. The evolution of the case was recorded by medical thermography, in addition to measuring pain intensity (visual analog scale) and functional capacity (toe touch test). Pain intensity (visual analog scale) decreased from seven at baseline to two at the end of treatment (after two ozone infiltrations, one weekly). Mobility of the damaged area (toe touch test) improved from a distance of 8 cm at baseline to 0 cm at the end of treatment. Regarding medical thermography, after the first and second infiltration of ozone, the temperature rose to a significant increase in perfusion from baseline from 31.2 to 31.8 °C and from 31.2 to 32 °C, respectively. These results suggest the possible interest of medical ozone as an adjuvant treatment for the recovery of sports tendinopathies and encourage us to carry out further studies.

Fixation of the Proximal Hamstring Tendon Using an All-Suture Tensionable Knotless Technique

Proximal hamstring injuries are a common sports and recreational injury among the active patient population. Surgical fixation of the tendons of the hamstring muscle complex, as opposed to conservative treatment alone, has shown improved patient outcomes, prompting the evolution of the suture anchors utilized in these repairs. Previous studies investigating the biomechanical properties of hamstring repair anchors have focused on double-row knotless techniques, in which the fixation of the overall construct relies on each individual anchor to maintain fixation. While these constructs have demonstrated biomechanical strength and clinical durability, each suture anchor represents a potential point of failure for the entire construct due to the crossed stitch anchor configuration. To address this limitation, recent tensionable knotless all-suture anchor designs have been implemented with success due to their smaller size and biomechanical strength. The aim of this technical note is, thus, to describe a technique for proximal hamstring repair using a tensionable knotless all-suture anchor construct that has 5 independent mattress sutures and, in doing so, employs the biomechanical strength of knotless fixation but eliminates the potential single point of failure seen with current knotless suture anchor designs.

Hamstring Injuries: Critical Analysis Review of Current Nonoperative Treatments

➢

Hamstring injuries are common among active and athletic individuals, especially those involved in high-speed running, distance running, or sports requiring sudden directional changes. Acute hamstring strains often occur as an eccentric strain during running or a stretch-type injury caused by simultaneous hip flexion and knee extension. Proximal hamstring tendinopathy is an overuse injury of the hamstring tendon as a result of chronic cicatrization of the musculotendinous unit.

➢

Repeated stress to the hamstring tendon leads to increased cellularity of tendon fibers, disruption of collagen, and subsequent microinjury of the tissue that attaches the tendon to bone.

➢

Management of hamstring injuries generally begins with nonoperative modalities consisting of eccentric rehabilitative exercise programs. Although various other treatment modalities are available, the comparative efficacy of these supportive measures is not well differentiated at this time.

➢

In this article, we review the current literature with regard to the nonoperative treatment of hamstring injuries, specifically focusing on acute hamstring muscle strains and proximal hamstring tendinopathy in order to provide supplementary insight on the effectiveness of current modalities.

Chronic Ischial Avulsion Fracture Excision With Primary Proximal Hamstring Repair: A Technique

Ischial avulsion fractures classically occur in the pediatric population and are relatively uncommon. These injuries are treated conservatively; however, in cases where there is greater than 2 cm of displacement, surgical intervention is recommended. In some cases, displaced fractures are either misdiagnosed or proper treatment is neglected, and patients who transition into adulthood are left with chronic nonunions that can become a source of pain and disability. Here we present a surgical technique for a chronic ischial avulsion fracture nonunion that is excised, and the hamstring tendons are then primarily repaired to the ischium using suture anchors.

Psychometric Properties of Four Common Clinical Tests for Assessing Hamstring Flexibility in Young Adults

Objective: To examine the psychometric properties of four common hamstring muscle flexibility tests involving the straight leg raise (SLR), passive knee extension (PKE), sit and reach test (SRT) and toe touch test (TTT) in young adults.

Methods: Forty-three young healthy adults (mean age 27.4 years) were recruited for 3 repeated sessions of hamstring flexibility assessments using the 4 tests mentioned above and the subsequent isokinetic examinations. The first two sessions (S1 and S2) were conducted by two different raters randomly on the first day (D1), and the third session (S3) was conducted by the same rater as S1 3 days later (D4). The next day (D5), the isokinetic performances of knee extensors and flexors of the dominant leg were assessed. To evaluate the interrater (S1 vs. S2) and test-retest (S1 vs. S3) reliability of hamstring flexibility tests, intraclass correlation coefficients (ICCs), standard errors of measurement, and the minimum detectable differences were calculated. Correlation analyses were performed to study the association of each hamstring flexibility test with the isokinetic muscle function of the knee flexors (H) and extensors (Q), including the peak torque (PT), total amount of work (TW) and average power (AP).

Results: Excellent interrater and test-retest reliability of hamstring flexibility tests involving the SLR, PKE, SRT and TTT were confirmed with ICCs ranging from 0.923 to 0.986. Fair correlations were found between the 4 hamstring flexibility tests and the H/Q for the PT at angular speeds of 180°/s (Pearson’s r at 0.330–0.449). In addition, the PKE was fairly correlated with the AP of the hamstring (Pearson’s r = 0.320) and the H/Q for the TW (Pearson’s r = 0.345) and AP (Pearson’s r = 0.386) at angular speeds of 180°/s.

Conclusions: This study confirmed that the SLR, PKE, SRT and TTT were reliable flexibility tests for hamstring muscles in young healthy adults, and the PKE might be a more valid outcome measure to predict hamstring injury.

Microwave Antenna System for Muscle Rupture Imaging with a Lossy Gel to Reduce Multipath Interference

Injuries to the hamstring muscles are an increasing problem in sports. Imaging plays a key role in diagnosing and managing athletes with muscle injuries, but there are several problems with conventional imaging modalities with respect to cost and availability. We hypothesized that microwave imaging could provide improved availability and lower costs and lead to improved and more accurate diagnostics. In this paper, a semicircular microwave imaging array with eight antennae was investigated. A key component in this system is the novel antenna design, which is based on a monopole antenna and a lossy gel. The purpose of the gel is to reduce the effects of multipath signals and improve the imaging quality. Several different gels have been manufactured and evaluated in imaging experiments. For comparison, corresponding simulations were performed. The results showed that the gels can effectively reduce the multipath signals and the imaging experiments resulted in significantly more stable and repeatable reconstructions when a lossy gel was used compared to when an almost non-lossy gel was used.

Effectiveness of High Power Laser Therapy on Pain and Isokinetic Peak Torque in Athletes with Proximal Hamstring Tendinopathy: A Randomized Trial

Athletes such as long-distance runners, sprinters, hockey, and/or football players may have proximal hamstring tendinopathy (PHT). Laser therapy has been shown to be effective in tendinopathies. High power laser therapy (HPLT) is used for the treatment of several musculoskeletal conditions; however, its efficacy on PHT has not been investigated. This study is aimed at examining the effects of HPLT on pain and isokinetic peak torque (IPT) in athletes with PHT. The two-arm comparative pretest-posttest experimental design was used with random allocation of 36 athletes aged 18-35 years into two groups (experimental and conventional group). The experimental group included the application of HPLT for 3 weeks. The conventional group included treatment with a conventional physiotherapy program including ultrasound therapy, moist heat pack, and home exercises for a total of 3 weeks. Pain and IPT of the hamstring muscle were measured before and after the application of the intervention. Pain score decreased, and IPT increased significantly (p < 0.05) after application of HPLT, by 61.26% and 13.18%, respectively. In the conventional group, a significant difference (p < 0.05) was observed in pain scores only, which decreased by 41.14%. No significant difference (p > 0.05) was observed in IPT in the conventional group. When HPLT was compared with conventional physiotherapy, a significant difference was found in pain scores only. HPLT for 3 weeks was found to be effective in improving pain in athletes with PHT. However, no significant difference was found between HPLT and conventional physiotherapy (US, moist heat, and home exercises) in improving the IPT of the hamstring muscle.

Isotonic and Isometric Exercise Interventions Improve the Hamstring Muscles’ Strength and Flexibility: A Narrative Review

Background: Hamstring weakness has been associated with an increased risk of hamstring strain, a common sports injury that occurs when athletes perform actions such as quick sprints. The hamstring complex comprises three distinct muscles: the long and short heads of the bicep femoris, the semimembranosus, and the semitendinosus. Methods: The researchers collected the data from different electronic databases: PubMed, Google Scholar, and the Web of Science. Results: Many studies have been conducted on the numerous benefits of hamstring strength, in terms of athletic performance and injury prevention. Isotonic and isometric exercises are commonly used to improve hamstring strength, with each exercise type having a unique effect on the hamstring muscles. Isotonic exercise improves the muscles’ strength, increasing their ability to resist any force, while isometric training increases strength and the muscles’ ability to produce power by changing the muscle length. Conclusions: These exercises, when performed at low intensity, but with high repetition, can be used by the healthy general population to prepare for training and daily exercise. This can improve hamstring muscle strength and flexibility, leading to enhanced performance and reduced injury risk.

The Brazilian version of the Victorian Institute of Sport Assessment - Hamstring (VISA-H) Questionnaire: Translation, cross-cultural adaptation and measurement properties

STUDY DESIGN

Study of diagnostic accuracy/assessment scale.

BACKGROUND

Proximal hamstring tendinopathy (PHT) usually causes disability, deep pain in the proximal insertion of the tendon, and limitations in daily life and sports practice. Scales that assess PHT pain and disability may assist practitioners in their clinical decision-making processes.

OBJECTIVES

To perform a translation, cross-cultural adaptation and to evaluate the measurement properties of the Victorian Institute of Sport Assessment - Hamstring (VISA-H) questionnaire for the Brazilian population.

METHODS

The VISA-H was adapted to Brazilian Portuguese (VISA-H-Br) and applied in 2 occasions with 5-8-day intervals. The following measurement properties were evaluated: internal consistency, test-retest reliability, standard error of the measurement (SEM), smallest detectable change (SDC), structural validity, and construct validity. Ninety (n = 90) participants (40 PHT and 50 asymptomatic participants) were evaluated using the Lower Extremity Functional Scale (LEFS) and VISA-H. PHT was diagnosed via clinical examination.

RESULTS

The questionnaire was successfully translated, cross-culturally adapted, and renamed VISA-H-Br. The VISA-H-Br questionnaire demonstrated high internal consistency (Cronbach α = 0.96), excellent test-retest reliability (ICC = 0.90, CI 95% 0.83-0.93), and strong construct validity (rho = 0.692, p < 0.01 compared to LEFS). The SEM was 2.15 points, and the SDC was 5.96 points. No ceiling or floor effects were detected.

CONCLUSION

The Brazilian version of the VISA-H was consistent, reliable, and valid. Therefore, it may be used in clinical practice and research to assess the pain and disability of patients with PHT.

Ultrasound assessment of the hamstrings complex of athletes with MRI correlation

Due to anatomical complexity, ultrasound examination of the hamstring muscles is challenging, resulting in potential diagnostic uncertainty and under-confidence in the technique. This leads to a subsequent tendency to favour magnetic resonance imaging (MRI) evaluation, which can delay diagnosis and potential intervention. This article describes a comprehensive technique of ultrasound evaluation of the hamstrings complex, using key anatomical landmarks. A direct comparison of the sonographic landmarks with corresponding MRI appearances is also provided. If these landmarks can be identified successfully, the complex anatomy can be unlocked, thus improving the time and sensitivity of diagnosis of acute injuries, as well as providing a reliable framework for monitoring injury progress and helping to identify candidates for potential intervention. Many of the anatomical landmarks discussed are common areas of injury in elite athletes, encountered frequently in clinical practice.

Female Athlete Hip Injuries: A Narrative Review

OBJECTIVE

In this narrative review, we highlight sex-specific anatomic and biomechanical features of the hip region in female athletes, as well as the potential impact of these characteristics on observed disparities in both intra-articular and extra-articular injury patterns between female and male athletes. It is our goal to broaden the scope of knowledge related to hip pathology in active female athletes among sports medicine providers with the hope of better optimizing sport participation and performance in female athletes.

DATA SOURCES

A literature review was conducted using PubMed database and Google Scholar search engine. Search terms included sport, female, athlete, sex differences, injury, hip, and all diagnoses discussed in this review. Cross-reference of these articles identified additional resources.

MAIN RESULTS

Sex-specific differences in both static design and dynamic function contribute to disparities in hip injury patterns between female and male athletes. Intra-articular injuries, including labral and ligamentum teres pathology, as well as extra-articular injuries, including iliopsoas tendon dysfunction, gluteal and proximal hamstring tendinopathy, ischiofemoral impingement, bone stress injuries, and certain nerve entrapment syndromes, seem to affect female athletes more commonly than male counterparts.

CONCLUSIONS

Given unique anatomic and functional considerations, the growing population of female athletes worldwide warrants specialized care and consideration. Potential predisposition to specific hip injuries should be taken into consideration during diagnostic evaluation of hip pain in the female athlete.

Distal Gracilis Tear in an Equestrian

ABSTRACT

A 61-yr-old female equestrian presented after 2 wks of left medial thigh pain, which developed suddenly while exiting a car. She denied any history of recent trauma or falls. On examination, she was found to have tenderness at the left distal medial thigh with a palpable region of decreased tissue volume at the gracilis myotendinous junction. Point-of-care ultrasound and magnetic resonance imaging confirmed a high-grade partial thickness tear of the left distal gracilis at the myotendinous junction, as well as pes anserine bursal distention. She received physical therapy and underwent a 1-time ultrasound-guided corticosteroid injection to the left pes anserine bursa. At follow-up, her symptoms had significantly improved, and she had returned to horseback riding after 12 wks. Isolated gracilis myotendinous tear is a rare condition, and this is a unique case with an atypical mechanism of injury as gracilis injuries have only been reported during vigorous exercise-related activities rather than transitional movements. This case illustrates the potential increased risk of distal gracilis injury after repetitive corticosteroid injections (genicular nerve blocks and radiofrequency lesioning) in a patient who was also likely predisposed to gracilis microtrauma due to her equestrian activities. Gracilis injury should be considered in the differential diagnosis of distal medial thigh pain, especially in cases with similar interventional and recreational profiles.

Pharmacological Treatment for Acute Traumatic Musculoskeletal Pain in Athletes

Pain management is a crucial issue for athletes who train and compete at the highest performance levels. There are still evidence gaps for the use of analgesics for sports injuries despite the growing interest in training and competition settings. However, high-quality research is needed to determine the most appropriate and optimal timing and formulations in non-steroidal anti-inflammatory drug and opioid management, particularly given the strictness of anti-doping regulations. Indeed, the role of pharmacological therapy in reducing acute traumatic pain in athletes should still be addressed to minimize the timing of return to sport. Therefore, the aim of this comprehensive review was to summarize the current evidence about pain management in the setting of acute injury in elite athletes, providing the most informed strategy for pain relief and performance recovery.

Mapping theme trends and recognizing research hot spots in the use of ultrasound in orthopaedics: a bibliometric analysis of global research

BACKGROUND

In the past decade, ultrasound has been increasingly used in the field of orthopaedics. The purpose of this study is to inspire future research in this field by analyzing the publications relating to ultrasound research in orthopaedics.

METHODS

All relevant articles published between 2009 and 2020 were retrieved from Web of Science. Statistical Package for Social Science and GraphPad Prism 8 software were used to generate and analyse diagrams. VOSviewer software and CiteSpace were employed to visualize the research trends based on co-occurring keywords. Finally, we obtained information about relevant clinical randomized controlled trials (http://clinicaltrials.gov.com/).

RESULTS

The United States had the most publications in this field and the most citations and the highest H-index. Furthermore, Skeletal Radiology published the most papers related to the use of ultrasound in orthopaedics, Ozcakar L published the most papers, and a study by Kwon, YM had the highest citation frequency. The keywords "MRI", "complication", "female" and "male" were identified as being indicative of emerging topics.

CONCLUSIONS

While the contribution of United States to publications in this field has been substantial, the future contributions of China cannot be ignored. Moreover, it is hypothesized that diagnostic and epidemiological aspects may become hotspots.

Cross-cultural adaptation of the Victorian institute of sports assessment - Hamstrings (VISA-H) questionnaire for Spanish speaking athletes with proximal hamstring tendinopathy

OBJECTIVE

To cross-culturally adapt and validate the Victorian Institute of Sports Assessment - Hamstrings (VISA-H) scale into Spanish.

DESIGN

Clinical measurement study (psychometric analysis).

SETTING

Sports clubs and physiotherapy clinics.

PARTICIPANTS

The Spanish version of the VISA-H (VISA-H-Sp) scale was administered to 101 subjects: 50 healthy runners and 51 patients with a clinical diagnosis of PHT.

MAIN MEASURES

The Victorian Institute of Sports Assessment - Hamstrings.

RESULTS

Cronbach's alpha for the VISA-H-Sp was >0.8. The ICC _2,1 was 0.993 (95%CI 0.991-0.995). In the exploratory factor analysis, a one-factor solution explained 72.1% of the total variance. Athletes with PHT scored significantly lower in the VISA-H-Sp than healthy subjects (P < 0.001). The VISA-H-Sp score results in the PHT group showed significant correlations with SF-36 physical components (Spearman r'>0.6; P < 0.001), and low or non-significant association with psychological dimensions. The standard error of measurement was 1.45 whereas the minimal detectable change was 4.02 points. The responsiveness indicators included an effect size of 2.75, and a standardised response mean of 3.1 at discharge.

CONCLUSION

The VISA-H-Sp shows adequate psychometric properties for assessing the severity of symptoms in Spanish-speaking athletes who suffer from PHT.

Pickleball: Review and Clinical Recommendations for this Fast-growing Sport

Pickleball is a single or doubles volley sport played with paddles and ball on a hardcourt. Growing in popularity in recent years, injuries can occur similar to racquet sports; however, there is a scarcity of references in the literature for sports medicine providers encountering these athletes and injuries. This review provides clinicians treating pickleball athletes with an overview of the sport, a case study demonstrating the significant injuries that can occur in pickleball, and a review of the available literature. We provide a discussion on common pickleball injuries, injury prevention strategies, and event coverage recommendations to better equip sports medicine providers with a base of knowledge and a clinical approach to treat these athletes, or "picklers," who enjoy this fast-growing sport.

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.

2019 Marathon of Rome. Hamstring injuries in long distance runners: influence of age, gender, weight, height, numbers of marathon and impact profile

BACKGROUND

Hamstring diseases are one of the most widespread diseases in athletes, especially in runners, sprinters, and endurance athletes. Notwithstanding the importance of the problem, risk factors are still marginally known. This transversal study analyzes the correlation between Hamstring tendinopathy and hamstring strains and age, gender, weight, height, number of marathons, and impact profile in athletes who took part in the 2019 Rome Marathon.

METHODS

At the 2019 Marathon of Rome, 700 runners (484 males and 216 females; mean age: 43.6 years, range 17-80 years) filled the VISA-H and FASH questionnaires. An adequately skilled orthopedic surgeon made a diagnosis of Hamstring tendinopathy and Hamstring strain injuries in line with clinical criteria.

RESULTS

A diagnosis of Hamstring tendinopathy was made in 537 participants while in 624 of hamstring strains. There was evidence of a positive correlation statistically significant between age, weight and impact profile with Hamstring strain injuries, while there was no association between sex and number of marathons and the Hamstring strains. No statistically significant positive correlation was found between all of the parameters analyzed and VISA-H. The association between VISA-H score and FASH score has resulted statistically significant.

CONCLUSIONS

In marathon athletes, there was not found evidence of a statistically significant correlation between gender, weight, height, number of marathons, impact profile and Hamstring tendinopathy. Nonetheless, age, weight and impact profile were associated with Hamstring strains, while sex and number of marathons had not shown statistically significant positive association with Hamstring strain injuries.

Proximal Hamstring Injuries

Proximal hamstring injuries can present as chronic tendinosis, acute strain, partial tendinous avulsions, or complete 3-tendon rupture. Nonoperative management for chronic insertional tendinosis and low-grade tears includes activity modification, anti-inflammatories, and physical therapy. Platelet-rich plasma injections, corticosteroid injections, dry needling, and shock wave therapy are newer therapies that also may provide benefit. Surgical indications include complete, proximal avulsions; partial avulsions with least 2 tendons injured with more than 2 cm of retraction in young, active patients; and partial avulsion injuries or chronic tendinosis that have failed nonoperative management. Surgical management entails open primary repair, endoscopic primary repair, or augmentation/reconstruction.

Platelet-Rich Plasma Injection for the Treatment of Hamstring Injuries: A Systematic Review and Meta-analysis With Best-Worst Case Analysis

BACKGROUND

Hamstring injuries are common and account for considerable time lost to play in athletes. Platelet-rich plasma has potential as a means to accelerate healing of these injuries.

PURPOSE

(1) To present the evidence of platelet-rich plasma injection in the treatment of hamstring injuries, (2) evaluate the "best-case scenario" in dichotomous outcomes, and (3) evaluate the "worst-case scenario" in dichotomous outcomes.

STUDY DESIGN

Systematic review and meta-analysis.

METHODS

Two authors systematically reviewed the PubMed, Embase, and Cochrane Library databases according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines, with any discrepancies resolved by mutual consensus. The level of evidence was assessed per the criteria of the Oxford Centre for Evidence-Based Medicine and the quality of evidence by the Coleman Methodology Score. Meta-analysis by fixed effects models was used if heterogeneity was low (I² < 25%) and random effects models if heterogeneity was moderate to high (I²≥ 25%). P values <.05 were considered statistically significant.

RESULTS

A total of 10 studies were included with 207 hamstring injuries in the platelet-rich plasma group and 149 in the control group. Random-effects model for mean time to return to play that compared platelet-rich plasma + physical therapy to physical therapy alone non-significantly favored platelet-rich plasma + physical therapy (mean difference, -5.67 days). The fixed effects model for reinjury rates, which also compared platelet-rich plasma + physical therapy with physical therapy alone nonsignificantly favored platelet-rich plasma + physical therapy (risk ratio, 0.88). The best-case scenario fixed effects model for reinjury rates nonsignificantly favored platelet-rich plasma + physical therapy (risk ratio, 0.82). The worst-case scenario fixed effects model for reinjury rates nonsignificantly favored physical therapy alone (risk ratio, 1.13). The mean ± SD complication rate for either postinjection discomfort, pain, or sciatic nerve irritation was 5.2% ± 2.9% (range, 2.7% to 9.1%).

CONCLUSION

There has been statistically nonsignificant evidence to suggest that PRP injection ± PT reduced mean time to RTP or reinjury rates compared to no treatment or PT alone for hamstring injuries in a short-term follow-up. The complication profiles were favorable. Further studies of high quality and large cohorts are needed to better support or disprove the consensus of the systematic review and meta-analysis.

Rare Fusion of the Semitendinosus and the Long Head of the Biceps Femoris Muscles in a Human Cadaver

During routine cadaveric dissection of a 59-year-old female cadaver, a rare, anomalous fusion of the semitendinosus and long head of the biceps femoris muscles, arising as a common head at the origin of the ischial tuberosity, was observed. In addition, a unilateral muscular slip was noted between the gluteus maximus and the long head of the biceps femoris muscle belly. To the best of our knowledge, this variation has not been previously reported in the literature. Such variations may increase the risk of hamstring injury or compression of the sciatic nerve. Patients presenting with sciatic pain in the posterior thigh may prompt an evaluation for the aberrant origin of the hamstring muscles. It may be beneficial for surgeons, radiologists, and sports medicine specialists to be aware of such variations due to potential implications on surgical intervention, pain management, and interpretation of radiographic images.

Load progression criteria in exercise programmes in lower limb tendinopathy: a systematic review

OBJECTIVE

The objective of this study is to summarise and analyse the current literature about what progression criteria are applied in loading exercise programmes in lower limb tendinopathies and their evidence and effectiveness.

DESIGN

Systematic review.

METHODS

PubMed, Embase, Scopus and PEDro were searched from inception to 24 September 2020. The inclusion criteria were randomised controlled trials that included patients with midportion Achilles, patellar or gluteal tendinopathy; assessed function, pain or performance; included at least one group where progressive physical exercise was administered as monotherapy; included at least a control group. We excluded studies that included subjects with previous tendon surgical treatment; studies with control group that conducted a supplemented modality of the exercise performed in the intervention group. A narrative synthesis was conducted. Cohen's d and the percentage of change of main clinical and performance outcomes were obtained. Methodological quality was assessed using the PEDro scale.

RESULTS

Thirty studies that described progression criteria were included. Six types of criteria grouped in two categories were identified and included in a new classification proposal: pain as a primary criterion (evoking and avoid-pain based), and pain and symptom control as a secondary criterion (conditioning stages, fatigue-based, subjective perception and temporary linear increase). Most of the studies applied a pain-based criterion. Criteria based on conditioning stages were also commonly applied. Other criteria such as fatigue, a temporary linear increase, or the subjective perception of the patient's abilities were occasionally applied.

CONCLUSIONS

There is a predominant use of pain-based criteria, but the utilisation of these criteria is not supported by strong evidence. This review evidences the need for studies that compare the same exercise programme using different progression criteria. A new classification of the existing progression criteria is proposed based on the use of pain as the primary or secondary criterion.

PROSPERO REGISTRATION NUMBER

CRD42018110997.

Hamstring muscle injury in the athlete: state of the art

Hamstring injuries (HSI) are the source of significant impairment and disability for both professional and recreational athletes. The incidence and prevalence of HSIs has been well documented in the literature, as they are among the most common soft tissue injuries reported. The significant time loss due to injury and the inherent risk of reinjury pose a significant issue to the athlete, their career longevity and the success of their respective team. This review will deal predominantly with describing the prevalence and incidence of HSI in athletes, discuss risk factors and the mechanisms of injury for HSI, how to properly diagnose, image and prognosticate appropriate return to sport (RTS) for individuals who have sustained an HSI, prescribe treatment and prevention strategies and to discuss relevant options to decrease overall risk of primary and secondary recurrence of HSI.Current treatments of acute HSI necessitate a thorough understanding of the mechanism of injury, identifying muscle imbalances and/or weakness, inclusion of eccentric and concentric hamstring (HS) and hip extension (HE) exercises, evaluation of pathokinematic movement patterns and use non-surgical methods to promote healing and RTS. This methodology can be used prospectively to mitigate the overall risk of HSI. Injection therapies for HSI, including ultrasound-guided platelet-rich plasma and corticosteroids, may impart some short-term benefit, but the existing literature is largely inconclusive with respect to long-term functional outcomes. Future directions should prioritise injury prevention, early diagnosis and targeted interventions that combine both non-surgical and minimally invasive orthobiological approaches and identifying biomechanical risk factors prospectively to mitigate risk.

Feasibility of supplemental robot-assisted knee flexion exercise following total knee arthroplasty

BACKGROUND

The Hybrid Assistive Limb (HAL) is a robotic exoskeleton designed to support impaired limbs.

OBJECTIVE

We aimed to evaluate whether active exercise using a single-joint HAL (HAL-SJ) following total knee arthroplasty can facilitate the recovery of knee flexion.

METHODS

Twenty-two patients who underwent total knee arthroplasty were randomly allocated to the HAL-SJ group (n= 12) or conventional physical therapy (CPT) group (n= 10). On postoperative day 5, patients performed active knee flexion exercises either with or without HAL-SJ assistance every second day. Outcome measures included active and passive knee flexion range of motion (ROM), muscle strength, and pain intensity, as assessed by the visual analog scale, and were assessed on postoperative days 5 (pre-treatment) and 10 (post-treatment). Active ROM was measured at 6 months postoperatively; further long-term follow-up was performed by telephone interview.

RESULTS

Both groups showed significant improvement between postoperative days 5 and 10 in all outcome measures. Improvements in active ROM (p< 0.01), passive ROM (p< 0.01), muscle strength (p< 0.01), and pain (p< 0.01) were significantly greater in the HAL-SJ group than in the CPT group. Long-term outcomes were also significantly better in the HAL-SJ group.

CONCLUSIONS

HAL therapy enables patients to perform painless active movements and facilitates the recovery of knee function.

Management of hamstring injuries: current concepts review

Injuries to the hamstring muscle complex are common in athletes, accounting for between 12% and 26% of all injuries sustained during sporting activities. Acute hamstring injuries often occur during sports that involve repetitive kicking or high-speed sprinting, such as American football, soccer, rugby, and athletics. They are also common in watersports, including waterskiing and surfing. Hamstring injuries can be career-threatening in elite athletes and are associated with an estimated risk of recurrence in between 14% and 63% of patients. The variability in prognosis and treatment of the different injury patterns highlights the importance of prompt diagnosis with magnetic resonance imaging (MRI) in order to classify injuries accurately and plan the appropriate management. Low-grade hamstring injuries may be treated with nonoperative measures including pain relief, eccentric lengthening exercises, and a graduated return to sport-specific activities. Nonoperative management is associated with highly variable times for convalescence and return to a pre-injury level of sporting function. Nonoperative management of high-grade hamstring injuries is associated with poor return to baseline function, residual muscle weakness and a high-risk of recurrence. Proximal hamstring avulsion injuries, high-grade musculotendinous tears, and chronic injuries with persistent weakness or functional compromise require surgical repair to enable return to a pre-injury level of sporting function and minimize the risk of recurrent injury. This article reviews the optimal diagnostic imaging methods and common classification systems used to guide the treatment of hamstring injuries. In addition, the indications and outcomes for both nonoperative and operative treatment are analyzed to provide an evidence-based management framework for these patients. Cite this article: Bone Joint J 2020;102-B(10):1281-1288.

Chronic High Hamstring Tendinopathy and Sacroiliac Segmental Dysfunction in a Mature Tae Kwon Do Athlete: A Case Study

Objective

This case study describes conservative management of high hamstring tendinopathy in a master's-age tae kwon do athlete.

Clinical Features

A 53-year-old female tae kwon do athlete of 10 years presented after ceasing activities of performance for over a year owing to chronic pain of insidious onset in the left buttock with radiation to the left hip and posterior thigh. The patient's pain was preventing her from being able to perform regular activities of daily living such as brisk walking or sitting. The pain was registered as a 7/10 on the numeric pain scale. Radiographs of the lumbopelvic area were negative. Conservative treatment localized the pain to the left ischial tuberosity. Magnetic resonance imaging showed bilateral trochanteric bursitis and left hamstring tendinopathy.

Intervention and Outcome

Following conservative management with therapeutic ultrasound over the hamstring origin, manual sacroiliac manipulation, and rehabilitation, she had complete resolution of symptoms.

Conclusion

This patient had a combination of pain syndromes including chronic high hamstring tendinopathy and sacroiliac joint dysfunction. There are many other factors that must be taken into consideration, including repetitive trauma of tae kwon do, age, and sex, that play a role in tendon and ligament changes over time. This case demonstrates management of coconditions and comorbidities that can be used in not only the athletic population but many other populations.

Platelet-rich plasma for treatment of chronic proximal hamstring tendinopathy

Aim: To determine whether platelet-rich plasma (PRP) can successfully treat symptoms associated with proximal hamstring tendinopathy. Materials & methods: Charts were retrospectively reviewed of patients with a diagnosis of chronic proximal hamstring tendinopathy who underwent an ultrasound-guided leukocyte-rich PRP injection to assess reported outcomes at baseline and final follow-up post-intervention. Results: In 22 patients with a mean age of 48.7 years and mean symptom duration of 26.5 months, mean Numeric Pain Rating Scale and Victorian Institute of Sport Assessment Scale for Proximal Hamstring Tendinopathy subscores demonstrated statistically significant improvements (p < 0.05) at a mean of 7.91 months follow-up. Sixty-eight percent of patients demonstrated ≥50% reduction of pain. Conclusion: Pain and functional outcomes improved following injection of PRP.

Orthobiologics for the Hip Region: A Narrative Review

Management of hip region disorders is challenging. Orthobiologic treatments including platelet rich plasma (PRP), mesenchymal stem cells, and amniotic injectables have gained popularity as promising treatments despite a lack of robust evidence for their effectiveness. We review rationale and current evidence for orthobiologics for three common hip region conditions: hip osteoarthritis, gluteal tendinopathy, and proximal hamstring tendinopathy. Overall, the current state of evidence is extremely limited for orthobiologic treatments and is predominantly relevant to PRP injections. There is currently a lack of data to support the use of mesenchymal stem cells or amniotic injectables in these conditions of the hip.

Practice patterns for the treatment of acute proximal hamstring ruptures

Objective: Proximal ischial hamstring avulsion injuries are relatively uncommon. As such, the management of these injuries is often highly variable. Consensus agreement is lacking for the indications for repair, along with the operative technique, and post-operative rehabilitation. The purpose of this study was to survey surgeons who treat proximal hamstring avulsion injuries to identify current trends in the management of this injury.Methods: After IRB approval, a 46-question cross-sectional survey was distributed using a secure electronic survey portal. The survey sought to determine surgeon experience, diagnostic preferences, treatment patterns, surgical indications/technique, perceived patient outcomes, surgical complications, as well as post-operative management and rehab protocols. Surveys were completed electronically and anonymously, with invitations distributed to members of the American Orthopedic Society for Sports Medicine (AOSSM) and Arthroscopy Association of Canada (AAC).Results: A total of 108 surgeons who manage proximal hamstring injuries completed the survey. Most respondents (77%) treat one to five of these injuries per year. MRI was the preferred imaging modality to confirm diagnosis. Despite 98% of respondents indicating that there was a role for surgical management of proximal hamstring avulsions, operative treatment was reportedly undertaken in only 50% of cases seen by each respondent. The top three reported surgical indications were: number of tendons involved (most important factor = 42%, second most = 26%, third most = 13%), amount of tendon retraction (28%, 41%, 16%), and patient activity level (16%, 18%, 24%).Conclusion: Based on the practice patterns of the surgeons who completed the survey, there is continued disparity in the management of proximal hamstring avulsions. A lack of agreement exists with regards to surgical indications, operative technique, and post-operative protocols. Most striking is the rate of non-operative treatment and perceived rate of poor outcomes within this cohort. Future research should focus on objective evaluation of non-operative management, and additional variables involved in surgical treatment and post-operative rehabilitation.

Fascial Hydrodissection for Chronic Hamstring Injury

Hamstring muscle injuries (HMI) are common among athletes. HMI can take many months to years to resolve. Often, athletes do not report complete resolution with typical conservative therapy. We present several cases of athletes who presented with chronic hamstring injuries that resolved immediately after being treated with an ultrasound-guided fascial hydrodissection procedure. Following the procedure and graded rehabilitation protocol, athletes reported resolution of pain and tightness in addition to increased performance and a quicker return to play.

Portal Placement and Biomechanical Performance of Endoscopic Proximal Hamstring Repair

BACKGROUND

Proximal hamstring tendon avulsions are debilitating and commonly cause pain, weakness, and functional limitations. Open surgical repair has been the standard, but improved endoscopic techniques have enabled proximal hamstring fixation with decreased risk of infection and numbness, without the morbidity of a large incision.

PURPOSE/HYPOTHESIS

The purpose was to (1) describe pertinent anatomy surrounding the proximal hamstring origin in relation to 4 endoscopic portal sites and (2) test for biomechanical differences between open and endoscopic repair. It was hypothesized that (1) endoscopic proximal hamstring repair is efficacious with respect to commonly used portals and (2) there is no biomechanical difference between open and endoscopic techniques.

STUDY DESIGN

Descriptive and controlled laboratory study.

METHODS

Proximal hamstring ruptures were simulated endoscopically in 10 fresh-frozen human cadaveric pelvis specimens. Endoscopic repair was then completed on 1 limb from each specimen through 4 portals. After repair, each specimen was dissected in layers and measurements from portal tracts to pertinent anatomy were obtained. Open repair was performed on all contralateral limbs, followed by cyclical biomechanical tensile testing to failure of both the open and endoscopically repaired hamstring tendons to assess failure load and local tissue strain.

RESULTS

On average, no portal tract was closer than 2.0 cm to the sciatic nerve or inferior gluteal neurovascular bundle. Anatomic landmarks were identified that could improve the reproducibility and safety of the procedure. Biomechanical testing revealed no differences between the open and endoscopic repair techniques for any measured parameter.

CONCLUSION

This study supports the safety and efficacy of endoscopic proximal hamstring repair through anatomic and biomechanical analyses and helps establish reproducible and recognizable landmarks that define a safe working zone.

CLINICAL RELEVANCE

This study maps the anatomic landscape of the proximal hamstring as encountered endoscopically and demonstrates equivalent biomechanical strength of endoscopic proximal hamstring repair, supporting this technique's safety and efficacy.

Is radial extracorporeal shock wave therapy combined with a specific rehabilitation program (rESWT + RP) more effective than sham-rESWT + RP for acute hamstring muscle complex injury type 3b in athletes? Study protocol for a prospective, randomized, double-blind, sham-controlled single centre trial

Background

Acute injuries of the hamstring muscle complex (HMC) type 3b (interfascicle/bundle-tear) are frequently observed in various sports disciplines both in elite and recreational sport. The treatment of choice of acute HMC injuries type 3b is a progressive physiotherapeutic exercise programme. Besides this, there is currently only insufficient scientific evidence to support other treatment methods, including local infiltrations and injections of platelet-rich-plasma. Very recently, it was demonstrated that extracorporeal shock wave therapy (ESWT) may accelerate regeneration after acute skeletal muscle injury. The aim of the present study is to test the hypothesis that the combination of radial ESWT (rESWT) and a specific rehabilitation program (RP) is effective and safe in treatment of acute HMC injury type 3b in athletes, and is statistically significantly more effective than the combination of sham-rESWT and RP.

Methods

We will perform a double blind, randomized, sham-controlled clinical trial at the clinic KinEf Kinesiología Deportiva, Ciudad Autónoma de Buenos Aires, Argentina. Forty patients with acute HMC injury type 3b will be randomly allocated to receive either rESWT (nine rESWT sessions; three sessions per week; 2500 radial extracorporeal shock waves (rESWs) per session; energy density depending on what the patient tolerates) or sham-rESWT. In addition, all patients will receive a specific rehabilitation program that will last for 8 weeks. The primary outcome measure will be the individual time (days) necessary to return to play. Secondary outcomes will include the presence or absence of reinjury during a time period of 6 months after inclusion into the study.

Discussion

Because of the lack of adequate treatment options for acute HMC injury type 3b in athletes and particularly the high reinjury rate, we hypothesize that the results of this trial will be of importance and have impact on clinical practice.

Trial registration

ClinicalTrials.gov ID NCT03473899. Registered March 22, 2018.

Editorial Commentary: Proximal Hamstring Injuries-Is the Hip to Blame?

There is a growing understanding of the relation between femoroacetabular impingement (FAI) and injury to adjacent structures. Patients with proximal hamstring pathology appear to have a high prevalence of underlying FAI. The kinetic chain phenomenon is a potential explanation of the high correlation between proximal hamstring injury and underlying FAI of the hip.

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.

Proximal Hamstring Repair: A Biomechanical Analysis of Variable Suture Anchor Constructs

Background:

Despite an abundance of literature regarding construct strength for a myriad of anchors and anchor configurations in the shoulder, there remains a paucity of biomechanical studies detailing the efficacy of these implants for proximal hamstring repair.

Purpose:

To biomechanically evaluate the ultimate failure load and failure mechanism of knotless and knotted anchor configurations for hamstring repair.

Study Design:

Controlled laboratory study.

Methods:

A total of 17 cadaveric specimens divided into 3 groups composed of intact hamstring tendons as well as 2 different anchor configurations (all-knotted and all-knotless) underwent first cyclic loading and subsequent maximal loading to failure. This protocol entailed a 10-N preload, followed by 100 cycles incrementally applied from 20 to 200 N at a frequency of 0.5 Hz, and ultimately followed by a load to failure with a loading rate of 33 mm/s. The ultimate failure load and mechanism of failure were recorded for each specimen, as was the maximal displacement of each bone-tendon interface subsequent to maximal loading. Analysis of variance was employed to calculate differences in the maximal load to failure as well as the maximal displacement between the 3 study groups. Holm-Sidak post hoc analysis was applied when necessary.

Results:

The all-knotless suture anchor construct failed at the highest maximal load of the 3 groups (767.18 ± 93.50 N), including that for the intact tendon group (750.58 ± 172.22 N). There was no statistically significant difference between the all-knotless and intact tendon groups; however, there was a statistically significant difference in load to failure when the all-knotless construct was compared with the all-knotted technique (549.56 ± 20.74 N) (P = .024). The most common mode of failure in both repair groups was at the suture-tendon interface, whereas the intact tendon group most frequently failed via avulsion of the tendon from its insertion site.

Conclusion:

Under biomechanical laboratory testing conditions, proximal hamstring repair using all-knotless suture anchors outperformed the all-knotted suture anchor configuration with regard to elongation during cyclic loading and maximal load to failure. Failure in the all-knotted repair group was at the suture-tendon interface in most cases, whereas the all-knotless construct failed most frequently at the musculotendinous junction.

Clinical Relevance:

No biomechanical studies have clearly identified the optimal anchor configuration to avert proximal hamstring repair failure. Delineating this ideal suture anchor construct and its strength compared with an intact hamstring tendon may alter the current standards for postoperative rehabilitation, which remain extremely conservative and onerous for these patients.

An evidence-based evaluation on the use of platelet rich plasma in orthopedics - a review of the literature

Within orthopedics, the use of platelet-rich plasma (PRP) has been rapidly increasing in popularity, however, its true effectiveness has yet to be fully established. Several studies find that injecting PRP to the site of injury does not provide any significant benefit with respect to clinical outcomes; however, many others report the contrary. Due to the conflicting evidence and multiple meta-analyses conducted on the topic, a literature review of high-quality evidence on the use of PRP for common orthopaedic conditions was performed. Thus far, the evidence appears to suggest that PRP may provide some benefit in patients who present with knee osteoarthritis or lateral epicondylitis. On the other hand, evidence appears to be inconsistent or shows a minimal benefit for PRP usage in rotator cuff repair, patellar and Achilles tendinopathies, hamstring injuries, anterior cruciate ligament (ACL) repair, and medial epicondylitis. There is limited confidence in the conclusions from the published meta-analyses due to issues with statistical pooling, and limited subgroup analyses exploring the substantial heterogeneity across studies. Evidence-based clinicians considering the use of PRP in their patients with musculoskeletal injuries should be weary that the literature appears to be inconsistent and thus far, inconclusive.

Rehabilitation and Prevention of Proximal Hamstring Tendinopathy

Proximal hamstring tendinopathy (PHT) comprises a small but significant portion of hamstring injuries in athletes, especially runners. PHT is a chronic condition that is clinically diagnosed but can be supported with imaging. The main presenting complaint is pain in the lower gluteal or ischial region that may or may not radiate along the hamstrings in the posterior thigh. There is little scientific evidence on which to base the rehabilitation management of PHT. Treatment is almost always conservative, with a focus on activity modification, addressing contributing biomechanical deficiencies, effective tendon loading including eccentric training, and ultrasound-guided interventional procedures which may facilitate rehabilitation. Surgery is limited to recalcitrant cases or those involving concomitant high-grade musculotendinous pathology. The keys to PHT management include early and accurate diagnosis, optimal rehabilitation to allow for a safe return to preinjury activity level, and preventative strategies to reduce risk of reinjury.