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managing the ruptured proximal hamstring

CHRISTOPHER C. DODSON, MD

DANIEL P. WOODS, MD

Editor’s Note: Okay, a quick reminder…as we go into this chapter on the hamstrings, remember we are talking about “the core.” We are not talking about just the hamstrings. Instead, we are talking about the whole thing—mid-chest to mid-thigh—our center that controls our whole body. Do not veer off this concept. Look at the balancing elephant in Figure 31-1, and ask what allows him (her?) to use its hamstrings and balance like this. It’s about the whole kit and caboodle, and how the caboodle interacts with the brain. The top works so effortlessly with the bottom; the sides work so naturally with each together. It’s remarkable. It’s not just the hamstrings, which do provide most of the strength of the posterior thigh. It’s also about how the strength works with the other cylinders in the engine room of this enormous creature.

Now consider the hamstrings. These are obviously important muscles. They are big. They take up much of the posterior thigh mass of humans and many creatures. So, they must provide much strength. But they also provide much more than that; for example, they contribute a huge part of our balancing and the elephant’s.

The hamstrings are hugely important in sport and in everyday life. To emphasize their importance in sports, all one has to do is look at the FIFA and other sports’ injury lists. Hamstring injuries usually lead the lists. Sports injury prevention protocols often segregate out the hamstrings and provide them with loads of, actually too much, attention. We will get to the latter point soon.

These are the hamstrings (Figure 31-2).

There are 3, the ones highlighted in red. In athletes, they get a lot bigger and take up most of the space of the posterior thigh. This is the traditional way to think about these muscles. It is necessary to think about the hamstrings’ attachments, their muscle mass and their importance in thigh extension. It is important to understand their anatomy, particularly if they are broken and you have to repair them.

But don’t think about the hamstrings in isolation. They are a big part of the core; as we said, almost all of the posterior thigh (Figure 31-3).

For rehabilitation or performance purposes, don’t think about the hamstrings as a segregated set of muscles. Like the rectus abdominis and other muscles, too much strengthening of the hamstrings sets up people for injury. Too many isolated hamstring exercises is one problem with the presently constructed FIFA injury prevention program. Think about all the recent hamstring injuries in prominent soccer players and ask if that program is working well. Don’t think a hamstring workout should be all about this (Figure 31-4)…

Think about the hamstrings as an enormous part of the bottom and posterior part of the core, a valuable part of our power. They attach to the butt muscles and, in turn, to the back muscles. The power does no good unless it attaches to the rest of our body. Think balance. Think about the elephant. We can abuse any muscle in our body by exercising them too much in isolation. We need to be particularly careful about that with the hamstring.

Consider workouts like Rob King’s.VID 1 With these, be careful still. The videos show people using a lot of weight. In reality you don’t need much, and you certainly have to work your way up.

Okay, time to get back to business. With respect to the core, we should not ignore the old, traditional ways to do things. Hamstring avulsions cause enormous problems. For an athlete, laborer, or anyone like ourselves who wants to stay somewhat fit, hamstring integrity is a large part of good core function. When that muscle group rips off, we should be aggressive about fixing it. I have asked one of my young colleagues, superstar sports medicine orthopedist Chris Dodson, to update us on this. Chris is now both the Sixers’ and the Eagles’ doc and asked his sports medicine fellow to join him in writing this chapter.

JOE THE TRUCK DRIVER

Joe, a 56-year-old male truck driver, loads his truck and slips on a patch of ice. His right thigh springs forward into a kind of forced hip flexion with his knee extended. He just did the “splits” for the first time in his life. At the same time, he felt a “pop” and a “ripping” in his posterior thigh. Immediately, he couldn’t sit without excruciating pain. Unable to walk or put any pressure whatsoever on his injured leg, he goes to the worker’s compensation physician. The doctor diagnoses a severe hamstring sprain. He starts on anti-inflammatories and rest.

Two months pass. He sees several more physicians and therapists who all advise time and physical therapy. He feels relatively okay, has much less pain, but still can’t sit without lots of pain and feels “real weak” in his lower extremity. Physical therapy focuses on strengthening the hamstrings, and during this he develops lots of new aches and pains in his back, flank, and abdomen. More time passes and the pain gets worse, and he begins to feel an electric sensation going down the injured leg, and then numbness and now pain from the thigh to below his knee. Frustration grows and he finally gets an MRI. He has a 3-tendon proximal hamstring avulsion and tremendous inflammation around the sciatic nerve associated with the retracted tendons. He sees an operative orthopedist.

After the initial evaluation, surgical intervention was planned to reattach the proximal hamstring. He and the surgeon discussed the possibility of utilizing an Achilles allograft if the tendons had retracted too far away. At surgery, the sciatic nerve was freed from impenetrable inflammatory strictures, and an Achilles allograft came into play. Overall, the surgery went well and the hamstrings fit back to their appropriate positions on the ischial tuberosity.

Postoperatively, Joe does well and has no pain with sitting at 2 months. His strength returns completely, and he is back at work after 6 months, able to perform just like he did before. Joe is finally happy.

Not all hamstring injuries are created equal. This patient had a severe central injury. It involved the central part of his core. It was disabling. Early recognition of this injury pattern would have avoided significant down time, pain and frustration.

THE WAY IT WAS

“It’s just a hamstring strain.” How many times have we heard that in our athletic careers? Rest, anti-inflammatories, physical therapy, and gradual return to play are all that’s necessary to return to action. It’s a very simplistic algorithm for treatment that does indeed lead to excellent outcomes in the vast majority of patients. But it does not always work. And you can usually recognize the ones that won’t get better with our simple, long-standing formula. There is a huge difference between a simple hamstring strain and a proximal hamstring tendinous avulsion.

Hamstring injuries in the athletic population are extremely common with the overwhelming majority treated successfully nonoperatively.¹ In the early 1900s, the evaluation of strains and sprains was thought to be very simple as “only a cursory examination”² was felt to be necessary in the diagnosis.³ As scientific and clinical evaluations became more sophisticated, the specifics of a muscular strain vs an actual avulsion became more clearly delineated. The advent of MRI brought about a clear understanding of the fact that a simple cursory evaluation is not always able to demonstrate clearly the extent of actual injury as often those strains diagnosed by the clinician can be over- or underrecognized in terms of severity.4 In the past 20 years, the evidence supports examining the specific location and pathoanatomical nature of the hamstring injury to determine the appropriate treatment regimen rather than symptom severity.^3,5

Some of the early management at the turn of the 20th century of such injuries included “holding the affected limb under cold water as long as you can bear it, and as often as possible,”⁶ plaster immobilization in the muscle fiber direction,⁷ which was popular until the 1950s⁶ with rest for 3 to 6 days followed by active work and massage creams.³ In the early 1900s, musculotendinous bone avulsions were first noted to be an injury that required a much longer period of immobilization,⁴ and as early as 1902, these injuries were treated with surgical intervention in the form of primary suture repair of avulsions.² As these injuries became recognized as responding better to operative intervention, newer techniques were developed including drill holes and primary suture repair, suturing of the ruptured portion of the hamstring tendon to surrounding tendons, and utilizing a fascia lata and carbon fiber graft to recreate the hamstring insertion on the ischial tuberosity.^8,9 With the advent of suture anchors and improved understanding of the particular injury patterns, the surgical indications and refined technique have allowed up to a 98% satisfaction rate and greater than 75% return of strength.¹⁰ Despite the advances in diagnostic and surgical capabilities, many of these injuries continue to be misdiagnosed and can lead to sciatic nerve irritation and prolonged hamstring weakness.¹⁰

THE WAY IT IS

Nomenclature

The concept of a proximal hamstring avulsion entails the detachment of the confluence of the 3 tendons: semitendinosus, semimembranosus, and long head of the biceps femoris from its insertion on the ischial tuberosity. This injury is the result of a forceful hip flexion with an extended knee. Various degrees of this injury include avulsion of one tendon, 2 tendons both with and without retraction, and avulsion of all 3 tendons. The degree of injury dictates conservative vs surgical treatment. An acute injury is defined as an avulsion surgically treated within the initial 4 weeks after the injury, whereas a chronic injury is greater than 4 weeks until surgical treatment is initiated. This injury occurs in both the athletic population and in middle-aged adults. It should be differentiated from a distal hamstring avulsion, which is treated conservatively very successfully, and an apophyseal injury in an adolescent, which is treated based on the degree of separation of the avulsed fragment. A chronic proximal hamstring tendinopathy is also a separate entity, which is caused by repeated stress on the hamstring insertion and is often encountered in endurance athletes. If separation of the proximal hamstring tendons occurs, it can be treated operatively.

Clinical Experience

Introduction

Advanced imaging techniques and recognition of this specific injury pattern have allowed appropriate identification of proximal hamstring avulsions. Despite the newer knowledge and diagnostic tools, still a large number of these injuries are overlooked as a recent case series noted the average time from injury to surgical intervention was 2.4 months.¹¹ Although surgical management of chronic hamstring avulsions has been nearly as successful as acute primary repair,¹² it increases the surgical difficulty as the avulsed tendons may have developed adhesions to the sciatic nerve and the loss of tendon length may require the addition of an allograft to reach its origin on the ischial tuberosity.¹⁰

History and Physical Examination

The initial evaluation of a patient with a suspected proximal hamstring avulsion should consist of a detailed history of the inciting event. The most common mechanism of injury consists of a forceful flexion of the hip with the knee in an extended position.^11,13,14 These injuries may occur in the younger athletic population while doing sporting activities, including running, jumping, kicking, and winter sports, or may occur in the middle-aged sedentary population often due to a fall or slip on ice with a similar mechanism.^13–15 The patient may report the sensation of a shot in his/her posterior thigh with subsequent pain near the ischial tuberosity and difficulty with ambulation. A stiff-legged gait that avoids hip flexion or knee extension is a common presentation.¹³ The patient often reports a significant amount of pain with sitting in the area of the avulsed tendon.

A thorough physical examination of the patient is paramount to determining the degree of hamstring injury, as well as recognizing which patients need additional imaging to determine the appropriate treatment. Initially the posterior thigh should be closely inspected, as the presence of a diffuse ecchymosis (Figure 31-5) may represent a significant myotendinous injury, vs a proximal or distal avulsion of the hamstring tendons.¹⁴ Next, the thigh should be palpated along the extent of the hamstring as with a proximal or distal avulsion there may be a palpable gap and thickened subcutaneous tissue near the area of injury.¹⁶ The range of motion should be assessed, and an increased popliteal angle in the affected extremity compared to the contralateral limb may indicate hamstring injury.¹⁷ The strength should be assessed with the patient prone with the knee in 90 degrees of flexion and an eccentric contraction with the knee in 30 degrees of flexion may recreate the mechanism of injury and aid in injury pattern recognition.¹⁴

Related posts:

Putting It All Together—A Patient’s Perspective on the Core How the Core Universe Forms The Eureka Moment for the Core Don’t Forget the Thorax Biomechanics Presenting…the Core!

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