Acute Proximal Hamstring Rupture
- Steven Cohen, MD and
- James Bradley, MD
Abstract
Hamstring strain is common in athletes, and both diagnosis and surgical treatment of this injury are becoming more common. Nonsurgical treatment of complete ruptures has resulted in complications such as muscle weakness and sciatic neuralgia. Surgical treatment recently has been advocated to repair the complete rupture of the hamstring tendons from the ischial tuberosity. Surgical repair involves a transverse incision in the gluteal crease, protection of the sciatic nerve, mobilization of the ruptured tendons, and repair to the ischial tuberosity with the use of suture anchors. Reports in the literature of surgical treatment of proximal hamstring rupture are few, and most series have had a relatively small number of patients. Surgical repair results project 58% to 85% rate of return to function and sports activity, near normal strength, and decreased pain.Acute hamstring strain is one of the more common injuries that occur in athletes.1 Strains typically result from an eccentric muscle contraction and most frequently occur at the musculotendinous junction. In general, mild to moderate strains respond well to nonsurgical treatments such as rest, ice, modalities (eg, ultrasound, electrical stimulation, edema control), nonsteroidal anti-inflammatory drugs (NSAIDs), gentle stretching, therapeutic exercise, and gradual return to athletic activity. Reports of surgical management are few.Mechanism of Injury and Presentation
Although infrequent, proximal hamstring rupture from the ischial tuberosity occurs acutely in both well-trained athletes and middle-aged individuals who sustain sudden hip flexion/knee extension causing hamstring contraction. Patients describe the injury as the sensation of being shot in the posterior thigh, and report subsequent difficulty ambulating.The stiff-legged gait pattern following injury is the result of the patient’s avoiding hip and knee flexion. Patients typically present with posterior thigh pain distal to the ischial tuberosity (at the location of the retracted tendon) and with significant ecchymosis as a result of the hematoma from the tendon rupture. Patients also report difficulty sitting secondary to pain at the avulsion site.2Physical Examination and Imaging
Determining the exact nature of the injury during physical examination is difficult because of the deep location of the hamstring muscle group. A common finding approximately 1 week after injury is a large, latent area of ecchymosis in the posterior middle and distal thigh. Although tenderness is usually present over the site of injury, palpation of a defect may or may not be easily established. Functional testing of the peroneal branch of the sciatic nerve is important because injury to this branch causes weakness of the short head of the biceps femoris muscle and may slow potential postoperative rehabilitation. Neurapraxia of the peroneal nerve may present as a footdrop or, more subtly, as an eversion weakness of the ankle.Radiographs typically are negative but may show a bony avulsion from the ischial tuberosity, if present. Magnetic resonance imaging (MRI) is crucial in determining the amount of soft-tissue injury—complete versus partial rupture, number of tendons ruptured, and amount of retraction (Figure 1). Digital radiographs, in particular MRI, allow extremely accurate measurement of the amount of retraction after tendon rupture.3Review of the Literature
The frequency of acute hamstring rupture appears to be increasing, both clinically and by reports in the literature, as middle-aged patients continue to be physically active and as the recognition and potential for treatment has become better established. Proper treatment includes a thorough evaluation and discussion with the patient regarding treatment options. Many of the reported series of proximal hamstring repair contain few patients; the largest series published to date of acute repair consists of seven patients.4 In addition, the technique for surgical repair is not well established. Published studies on the surgical treatment of proximal hamstring injuries are few, contain both acute and chronic tears, and include relatively small numbers of patients2,4-8(Table 1).Klingele and Sallay4 reported on the primary surgical repair of complete proximal hamstring ruptures in 11 patients. Average age was 41.5 years and the mechanism of injury varied. MRI was used to confirm complete injuries in all patients. Surgery was recommended for acute complete rupture in active patients with functional disability as well as in patients with chronic pain caused by sciatic nerve compression and who are unable to return to vigorous activity.Chakravarthy et al5 reported on the surgical treatment of complete proximal hamstring tendon ruptures in four patients (two water skiers, two bull riders). Two of the three patients initially treated nonsurgically had sciatic neuralgia, and all four had significant knee flexion weakness and thigh pain.Cross et al6 reported on the surgical repair of chronic complete rupture in nine adult patients. The authors felt that the acute diagnosis of complete rupture was difficult to determine because of a general lack of awareness by clinicians of the diagnosis. At an average of 48 months, hamstring strength and endurance averaged 60% and 57%, respectively, in the seven of nine patients available for testing.Brucker and Imhoff7 described the functional assessment after acute and chronic hamstring repairs in eight patients. The authors performed Cybex dynamometer isokinetic testing to measure maximum hamstring and quadriceps muscle torque as well as hamstring-to-quadriceps peak torque ratio at a velocity of 60°/s. MRI was used to confirm the diagnosis in all patients. Return to sports activities was allowed after 6 to 8 months in all patients. At an average follow-up of 20 months, four patients (50%) reported incisional pain and discomfort. One patient required an additional surgery after pullout of a metal suture anchor.Sallay et al8 described the results of 12 patients with chronic hamstring injuries related to water skiing incidents. Average time from injury to initial evaluation was 5.6 months (range, 6 weeks to 18 years). In novice skiers, the mechanism commonly was an eccentric contraction while attempting to get up from the submerged position; in expert skiers, the mechanism was injury from a fall. Initial treatment was nonsurgical; half of the patients had MRI or computed tomography (CT) scans to assess the injury. Five MRI scans and one CT scan were used to evaluate the exact site and extent of the hamstring tear. Five patients ultimately had delayed surgical repair because of persistent functional limitations. This study confirmed the functional deficit associated with complete proximal hamstring tears.Orava and Kujala2 surgically treated eight patients who had complete rupture (all three tendons) of the hamstrings from the ischial tuberosity. Mean patient age was 40 years. The injury in each resulted from a sudden forceful flexion of the hip when the knee was extended and occurred during athletic activity. In seven of the eight patients, ultrasound was used to confirm complete tendon rupture. Function and strength improved in the five patients who underwent repair <2 months after the injury compared with loss of function and strength in the three patients with delayed diagnosis and chronic repair. Acute repair allows easier reapproximation of the tendon to its insertion on the ischial tuberosity. The authors in conclusion recommended nonsurgical treatment of isolated biceps femoris ruptures because little functional disability results from this injury, while they recommended prompt surgery to accomplish primary repair of the combined hamstring tendon to its origin.Management
We use a treatment algorithm and recommend nonsurgical treatment to manage a single tendon avulsion with retraction of up to 1 to 2 cm. In our experience, athletes are able to return to high-level sports (eg, professional football) approximately 6 weeks after such injury. The single tendon rupture scars to the intact tendons and usually allows return to full strength. An acute three-tendon tear (ie, semitendinosus, semimembranosus, and long head of biceps femoris) typically has a significant amount of retraction of ≥5 cm, and this injury is treated with surgical repair.Determining how to treat a two-tendon rupture is a more difficult decision. Although MRI findings may show avulsion of two tendons, the third may have a significant injury associated at the musculotendinous junction and may be attenuated. We recommend surgical repair in young (aged <50 years), active individuals, especially those still participating in athletics who have retraction of the ruptured tendons of ≥2 cm. However, there are no specific guidelines in the literature on the amount of retraction that should be treated surgically. In our experience, retraction of ≥2 cm has been the decisive factor for surgical treatment. We have noted that retraction of 2 cm of the two tendons has been indicative of an injury to the third tendon, usually at the musculotendinous junction or muscle belly, although the injury may not be apparent on MRI. Failure to address this injury surgically may result in residual pain, weakness, and hamstring dysfunction.Nonsurgical Management
Nonsurgical management is recommended in the case of a single- tendon rupture regardless of the amount of retraction and in a multiple-tendon tear with minimal retraction (<2 cm). Treatment consists of rest, ice, modalities (eg, ultrasound, electrical stimulation, edema control), NSAIDs, gentle stretching, therapeutic exercise, and gradual return to athletic activity over approximately 4 to 6 weeks.Nonsurgical treatment of significant proximal hamstring ruptures (ie, two or more tendons) may result in knee flexion weakness and mild hip extension weakness, difficulty sitting, deformity, and the potential development of symptoms similar to those of hamstring syndrome as the tendons scar down to the sciatic nerve. Hamstring syndrome consists of local posterior buttock pain and discomfort over the ischial tuberosity.9 In most patients, the discomfort begins without specific trauma and characteristically is painful during sitting. In addition, the pain may worsen with stretching and during exercise (eg, sprinting, hurdling, kicking). In cases of persistent hamstring syndrome, surgical release and sciatic nerve decompression are necessary to relieve the symptoms; this was successful in 52 of 59 patients (88%) in one series.9Acute repair allows easier mobilization of the tendons (usually a single tendon wad comprising all three tendons) and permits repair to the ischial tuberosity. Chronic rupture repair yields less consistent results; the potential exists of scarring to the sciatic nerve, which could require concomitant dissection of the nerve from the avulsed tendons, followed by sciatic neurolysis.Surgical Management
Surgical management is recommended when two hamstrings (retraction >2 cm) or three hamstrings are avulsed from the ischial tuberosity.The patient is placed in the prone position on the operating table, and a transverse incision is made in the gluteal crease directly inferior to the ischial tuberosity. Rather than a longitudinal incision, we prefer a transverse incision in the gluteal crease, both for its cosmesis and its accessibility to the avulsed tendons. When necessary, the transverse incision may be extended to provide greater access for retrieval of any retracted tendons. The incision is taken down to the gluteal fascia, taking care to avoid the posterior femoral cutaneous nerve. A transverse incision is made in the gluteal fascia. The gluteus maximus muscle is elevated and retracted superiorly. This allows exposure of the hamstring fascia.A longitudinal incision is made in the hamstring fascia. Typically, an additional layer of fibrous tissue (scar) lies over the ruptured coalescence of the hamstring tendons; it will therefore appear that tendons are not ruptured, but this layer must be incised to locate the tendons. Entering this layer exposes the large amount of hematoma that is present from the tendon rupture.The sciatic nerve can be palpated and protected by lateral retraction of the group of tendons. After the tendons are identified, the fibratic tissue on the ends of the tendon is removed, and the tendon edges are resected to normal tendon (Figure 2). It is crucial not to be excessive in removing the reactive scar tissue; otherwise, the tendon length is shortened.The tendons are mobilized and tagged with a heavy suture. Next, the ischial tuberosity is identified, and the lateral aspect is cleared off with a periosteal elevator. It is important to reattach the tendons to their anatomic origin, which is on the lateral aspect of the tuberosity. The anatomic origin of the semimembranosus tendon is the most lateral; the semitendinosus and long head of the biceps femoris are medial to the origin of the semimembranosus tendon, arising from a common aponeurosis9 (Figure 2).The tuberosity is denuded using curets, to provide for healing of the tendon origins to bone (Sharpey’s fibers). The tendons are repaired to bone with the use of suture anchors. We prefer the bioabsorbable anchors with abrasion-resistant suture because of the strength of the suture and the lower knot profile. The anchors are placed in the configuration of an “X” using a total of five anchors (Figure 3). The sutures are passed through the tendons using horizontal mattress sutures from inferior to superior and are tied down from superior to inferior with the knee flexed 30°. We have not had success using Bunnell, modified Kessler, or modified Mason-Allen stitches because those stitches tend to bunch up the tendon at the bony interface on the ischial tuberosity.The fascia is closed, and the wound is closed in layers. The affected leg is then placed in a custom-fitted hip orthosis that restricts hip flexion to a range of only 15° to 30° (Figure 4). Limiting hip motion limits the stress at the reattachment site. The patient then ambulates on crutches with toe-touch weight bearing.The first phase of rehabilitation consists of toe-touch weight bearing for 10 to 14 days, with advancement to 25% weight bearing for the next 3 weeks. This allows slight hip and knee flexion, taking care to prevent any stress on the tendon repair. Passive range of motion of the knee and hip is begun at week 2, and gentle active range of motion is initiated by week 4. The brace is discontinued by week 6.The second phase starts with full weight bearing at week 6 and normal gait training. Passive and active ranges of motion are progressed, and aquatherapy is introduced. Isotonic exercises are begun within a limited range of motion, avoiding the terminal ranges of motion. Core pelvic strength training and closed-chain exercises also are initiated. At 8 weeks after surgery, isotonic strength training is progressed, and dynamic training is advanced. An isometric strength evaluation at 60° of knee flexion is performed at 10 weeks.After 10 weeks, the final phase of rehabilitation begins with the initiation of dry land jogging. A full isokinetic evaluation is performed at 60°/s, 120°/s, and 180°/s and compared with results from the nonsurgical side. This evaluation provides objective evidence of strength deficits for patients and therapists and allows specific milestones for return to sport. Sport-specific activities are continued; return to sporting activity is permitted when isokinetic testing is 80% of the unaffected side—similar to the protocol for return for patients after anterior cruciate ligament reconstruction.10 Typically this occurs between 6 and 9 months.Our current series of acute hamstring repairs includes seven patients with eight hamstring repairs (one bilateral). Patient ages ranged from 24 to 58 years. All injuries resulted from an eccentric contraction of the hamstrings, and all repairs were performed with the surgical technique described at an average of 5.7 days after injury. The average time to return to function/athletics was 8.5 months. At latest follow-up (>6 months), all patients were satisfied with the procedure, and six of seven had returned to preoperative sport and daily activity levels.Summary
Hamstring strain is a common injury; complete proximal hamstring rupture occurs less frequently. Surgeons must develop awareness for these injuries and perform a careful physical examination, supplemented by the use of MRI, to avoid missing the diagnosis. Acute surgical treatment of proximal hamstring avulsions allows anatomic repair and lessens symptoms similar to those of hamstring syndrome. Acute anatomic repair also allows most patients to achieve functional return to activities, including high-level athletics.Figures
Figure 1Coronal (A) and axial (B) T2-weighted MRI scans in a patient with acute complete proximal hamstring rupture from the ischial tuberosity of the hip and pelvis.
Figure 2Origin (A) and appearance of the proximal hamstring tendons with retraction after rupture from the insertion on the lateral aspect of the ischial tuberosity (B). C, Anatomy of the hamstring muscles and their origin on the ischial tuberosity.
Figure 3Depiction of the proximal hamstring repair on the ischial tuberosity with the use of five suture anchors in the “X” configuration.
Figure 4Front (A) and side (B) views of postoperative brace worn following proximal hamstring repair.Tables
View this table:Table 1 Summary of Studies on Proximal Hamstring RepairReferences
- Evidence-based Medicine: There are no level I/II randomized prospective studies referenced. The majority of references represent level III/IV case-control reports or cohort studies. An expert opinion review previously published in this journal is cited (reference 1).Citation numbers printed in bold type indicate references published within the past 5 years.
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