Adolescent hamstring avulsions that simulate tumors

Hamstring injuries are common in athletes. Most of these injuries are diagnosed clinically and managed conservatively. Some patients, such as those with atypical clinical presentations or persistent pain, may be referred for imaging evaluation. In this subacute setting, studies obtained may have confusing features, and fractures may be mistaken for neoplasms. Hamstring avulsions, as seen on plain radiographs and conventional tomography, can have an aggressive appearance owing to callus and postfracture osteolysis. Although computed tomography is not usually necessary, it is very helpful in the subacute setting, identifying the healing avulsed apophysis. Familiarity with the appearance of ischial avulsions over time and with different modalities facilitates accurate characterization of hamstring injuries. We present our experience with six ischial avulsion fractures referred to us as tumors.     

Treatment of proximal hamstring ruptures - a systematic review

Proximal hamstring ruptures are increasingly treated surgically, despite little high-level supporting evidence. We sought to determine whether there are differences in clinical outcome after surgical vs. non-surgical treatment of proximal hamstring tendinous avulsions/ruptures and acute vs. chronic surgical repair of tendinous avulsions. Multiple medical databases were searched for Level I-IV evidence. 18 studies were included. 298 subjects (300 proximal hamstring injuries) were analyzed with mean age of 39.7 years. 286 injuries were managed with surgical repair vs. 14 non-operative. 95 surgical cases were performed within 4 weeks of the injury (acute), while 191 were performed beyond 4 weeks (chronic). 292 injuries were tendinous avulsions while 8 were bony tuberosity avulsions. Surgical repair resulted in significantly (p < 0.05) better subjective outcomes, greater rate of return to pre-injury level of sport, and greater strength/endurance than non-surgical management. Similarly, acute surgical repair had significantly better patient satisfaction, subjective outcomes, pain relief, strength/endurance, and higher rate of return to pre-injury level of sport than chronic repair (p < 0.001) with reduced risk of complications and re-rupture (p < 0.05). Chronic surgical repair also improves outcomes, strength and endurance, and return-to-sport, but not as well as acute repair. Non-operative treatment results in reduced patient satisfaction, with significantly lower rates of return to pre-injury level of sport and reduced hamstring muscle strength.     

Imaging of the hamstrings

The hamstring muscles, located in the posterior thigh, include the biceps femoris, the semimembranosus, and the semitendinosus. The proximal portions of the hamstring muscles are subject to a variety of injuries and pathology. Many of these entities affect the origin of the hamstrings, including the tendinous enthesis, the underlying ischial tuberosity, and the surrounding tissues. Tendinosis and small partial tears at the origin are the result of chronic attrition. They may be accompanied by bursitis or hamstring syndrome. Apophysitis occurs in teenagers prior to complete fusion of the ischial apophysis and results from repeated traction injuries on the apophysis without discrete displacement. Abrupt injury at the origin from forced flexion of the hip results in osseous avulsions of the apophysis in teenagers and proximal tendon ruptures in adults. Other entities affect the muscles distal to the tendon origins. These injuries include strains and partial tears of the musculotendinous junction from acute indirect trauma, delayed onset muscle soreness from overuse of the muscle group without discrete remembered injury, and contusions and myositis ossificans from direct blunt impact. The imaging features of these injuries and pathology are fairly specific and diagnostic, with the exception of some cases of myositis ossificans and chronic ischial avulsions.     

Practice patterns for the treatment of acute proximal hamstring ruptures

ABSTRACT

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.     

Evaluation of the hamstring muscle complex following acute injury

Objective To evaluate the imaging findings following acute hamstring injury.Design and patients We retrospectively reviewed the imaging findings of hamstring muscle complex (HMC) strain in 170 patients referred to our institution over a 3-year period. A total of 179 injuries to the HMC were demonstrated in 170 patients (154 male, 16 female, mean age 28.2 years). The mean duration of symptoms was 4.7 days (range 1–10 days). MR imaging was performed in 97 cases and sonography in 102 cases (both modalities were performed in 20 examinations). Attention was directed to the frequency of muscle involvement, the location of the injury within the muscle-tendon unit, the extent of the injury and discriminating avulsion from muscle injury.Results and conclusions Twenty-one patients had proximal tendon injury, with sixteen avulsions and five partial tears. Sixteen of these patients had surgical confirmation of hamstring avulsion from the ischial tuberosity (14 conjoint, 2 biceps femoris alone) and all were reliably diagnosed with MR imaging (16/16), but less so with sonography (7/12). Four distal tendon avulsions were also observed (three semitendinosus, one biceps femoris). With respect to muscle injury, the biceps femoris was most commonly injured (124/154). Semimembranosus was an uncommon muscle injury (21/154) and semitendinosus rare (9/154). Imaging can discriminate a hamstring tendon avulsion from musculotendinous strain and helps identify which patients necessitate surgical management as opposed to conservative treatment.     

Displaced avulsion of the ischial apophysis: a hamstring injury requiring internal fixation

A case is reported of an adolescent sprinter who was chronically disabled by pain after non-operative management for an acute hamstring injury. He had sustained an avulsion fracture of the ischial apophysis with displacement of 2.5 cm. Avulsion fractures of the ischial apophysis with displacement of 2 cm or more are unusual, but they frequently result in a symptomatic non-union, and early diagnosis, open reduction, and internal fixation is to be encouraged.


     

Surgical repair of complete proximal hamstring tendon rupture

BACKGROUND: Complete proximal hamstring tendon rupture is a rare injury associated with significant functional loss. Nonoperative treatment has proven inadequate in returning patients to their previous activity level. PURPOSE: We wanted to describe the outcome of primary surgical repair of the proximal hamstring tendon avulsion. STUDY DESIGN: Retrospective cohort study. METHODS: Between 1994 and 1999, 11 patients (4 women and 7 men) with an average age of 41.5 years (range, 21 to 51) had a diagnosis of complete proximal hamstring tendon rupture based on mechanism of injury, physical examination, and radiographic assessment. All underwent a single operation followed by standard postoperative physical therapy. At the latest follow-up (average, 34 months), patients completed a questionnaire regarding such outcome parameters as pain, function, leg control, stiffness, return to activity, and overall satisfaction. RESULTS: Isokinetic muscle testing revealed an overall average of 91%return of hamstring muscle strength. Ten of 11 patients were satisfied with the result, and 7 of 9 athletically active patients were able to return to sport an average of 6 months (range, 3 to 10) after surgery. No difference between early and late repairs was identified in regard to functional outcome or return to sport. CONCLUSIONS: Satisfactory results can be achieved with both early and late hamstring tendon repairs in a majority of cases with surgical repair.     

Hamstring strains and tears in the athlete

Hamstring injuries continue to be very common for both elite and amateur athletes. Given their high recurrence rate, the ability to treat these injuries effectively is critical to helping athletes return to their previous level of activity without putting them at risk for future injury. Most hamstring strains can be treated with initial pain control and a course of rehabilitation focused on a gradual return to activity. However, an exact, evidence-based rehabilitation protocol has yet to be studied. Although surgery is rare and reserved for complete hamstring ruptures, results show high patient satisfaction and ability to return to play.     

Acute first-time hamstring strains during high-speed running: a longitudinal study including clinical and magnetic resonance imaging findings

BACKGROUND: Hamstring muscle strain is one of the most common injuries in sports. Still, knowledge is limited about the progression of clinical and magnetic resonance imaging characteristics and their association with recovery time in athletes. HYPOTHESIS: Knowing the anatomical location and extent of an acute first-time hamstring strain in athletes is critical for the prognosis of recovery time. STUDY DESIGN: Case series (prognosis); Level of evidence, 2. METHODS: Eighteen elite sprinters with acute first-time hamstring strains were prospectively included in the study. All subjects were examined, clinically and with magnetic resonance imaging, on 4 occasions after injury: at day 2 to 4, 10, 21, and 42. The clinical follow-up period was 2 years. RESULTS: All sprinters were injured during competitive sprinting, and the primary injuries were all located in the long head of the biceps femoris muscle. There was an association between the time to return to pre-injury level (median, 16; range, 6-50 weeks) and the extent of the injury, as indicated by the magnetic resonance imaging parameters. Involvement of the proximal free tendon, as estimated by MRI, and proximity to the ischial tuberosity, as estimated both by palpation and magnetic resonance imaging, were associated with longer time to return to pre-injury level. CONCLUSION: Careful palpation during the first 3 weeks after injury and magnetic resonance imaging investigation performed during the first 6 weeks after injury provide valuable information that can be used to predict the time to return to pre-injury level of performance in elite sprinting.     

Return to sport and beyond following intramuscular tendon hamstring injury: A case report of an English Premier League football player

BackgroundHamstring strain injuries are the most common type of injury in elite football and are associated with a high risk of reinjury, particularly those involving the intramuscular tendon (IMT). Limited information is available regarding the rehabilitation and return to sport (RTS) processes following such injuries. This case study describes the clinical presentation of an elite football player following IMT hamstring injury, their on- and off-pitch rehabilitation alongside performance monitoring throughout RTS and beyond.Case scenarioAn elite football player suffered a grade 2c hamstring injury during an English Premier League (EPL) match. The player underwent early post-injury management, alongside progressive off-pitch physical preparation. The ‘control-chaos continuum’ was used as a framework for on-pitch rehabilitation to prepare the player for a return to full team training and competition. Objective and subjective markers of the player's response to progressive on- and off-pitch loading were monitored throughout RTS and beyond.OutcomesThe player returned to on-pitch rehabilitation after 11 days, to full team training having achieved weekly pre-injury chronic running load outputs after 35 days and played in the EPL 40 days post-injury. The player did not suffer reinjury for the rest of the EPL season.ConclusionAn understanding the unique structural and mechanical properties of the IMT, alongside expected RTS timeframes are important to inform rehabilitation and decision-making processes post-injury. Performance and frequent load-response monitoring throughout RTS and beyond, in conjunction with practitioner experience and effective communication are critical in facilitating effective RTS and reduce risk of reinjury following IMT injury.     

Hamstring injuries. Proposed aetiological factors, prevention, and treatment

Injuries to the hamstring muscles can be devastating to the athlete because these injuries frequently heal slowly and have a tendency to recur. It is thought that many of the recurrent injuries to the hamstring musculotendinous unit are the result of inadequate rehabilitation following the initial injury. The severity of hamstring injuries is usually of first or second degree, but occasionally third-degree injuries (complete rupture of the musculotendinous unit) do occur. Most hamstring strain injuries occur while running or sprinting. Several aetiological factors have been proposed as being related to injury of the hamstring musculotendinous unit. They include: poor flexibility, inadequate muscle strength and/or endurance, dyssynergic muscle contraction during running, insufficient warm-up and stretching prior to exercise, awkward running style, and a return to activity before complete rehabilitation following injury. Treatment for hamstring injuries includes rest and immobilisation immediately following injury and then a gradually increasing programme of mobilisation, strengthening, and activity. Permission to return to athletic competition should be withheld until full rehabilitation has been achieved (complete return of muscle strength, endurance, and flexibility in addition to a return of co-ordination and athletic agility). Failure to achieve full rehabilitation will only predispose the athlete to recurrent injury. The best treatment for hamstring injuries is prevention, which should include training to maintain and/or improve strength, flexibility, endurance, co-ordination, and agility.     

Surgical repair of complete proximal hamstring tendon ruptures in water skiers and bull riders: a report of four cases and review of the literature

Objective: Hamstring strains are one of the most common muscle strains in athletes; however, complete rupture of the proximal hamstring origin is rare and results from significant trauma. The objective of this paper is to present our experience of management of complete ruptures where surgical repair resulted in good results in both acute and delayed cases. Methods: Two water skiers and two bull riders sustained complete rupture of the proximal origin of the hamstring muscles. All underwent repair of the hamstring origin and sciatic nerve neurolysis. A post operative hamstring rehabilitation programme was instituted. Regular follow up was performed at 2, 3, 6, 9, and 12 months. Results: At a minimum final follow up of 12 months all patients had regained functional knee flexion strength with no pain and a near normal range of knee flexion. All four individuals were able to return to their previous line of work and three were able to return to their pre-injury level of sport. Conclusion: Complete rupture of the hamstring origin is a potentially devastating sports injury that has implications affecting the individual''s activities of daily living as well as potential as a sportsperson. Surgical repair restores the distorted anatomy, allows early functional rehabilitation, and avoids the potential debilitating neurological problem of gluteal sciatica.     

Total proximal tendon avulsion of the rectus femoris muscle

Total proximal avulsions of the quadriceps femoris muscle group are rare injuries. Between the years 2001 and 2004 five patients with a total proximal avulsion of the tendon of the rectus femoris muscle were treated surgically in Mehiläinen Hospital in Turku, Finland. The median age of the patients was 21 years (range, 19–27) and the patients were all men. There were four soccer players and one hurdler. In all cases an avulsion of the proximal tendon of the rectus femoris muscle was confirmed by MRI. All of the patients were operated on and the delay from the injury to surgery ranged from 18 to 102 days. The result of the surgical treatment was rated good in all cases. All of the patients were able to return to their pre‐injury level of activity 5–10 months after surgery. The median follow‐up time was 20 months (range, 9–38). Surgical treatment of a total proximal avulsion of the tendon of the rectus femoris muscle seems to result in return to the pre‐injury activity level in most cases.     

Nordic strength and history of hamstring injury in Australian Football League players

ObjectivesCompare hamstring strength between Australian Football League (AFL) players with and without a prior hamstring injury and determine the effect of the number of previous hamstring injuries, time since the last injury, and injury severity, on hamstring strength.DesignCross-sectional, retrospective.SettingAFL clubs.Participants124 AFL players.Main outcome measuresBilateral hamstring strength was assessed on a Nordbord (Vald Performance) during the Nordic Hamstring Exercise. Self-reported questionnaires were used to record previous hamstring injuries. Players were categorized into No Injury or Hamstring Injury groups. Previously injured players were subgrouped based on number of prior hamstring injuries (single or multiple), time since the last hamstring injury (≤1 or > 1-year ago), and hamstring injury severity (≤3 or > 3 matches missed).Results19 hamstring injuries were reported. Hamstring strength was not different between players with and without a history of hamstring injury when assessed in absolute (N) or relative (i.e., N.kg⁻¹) terms. No differences in strength were detected between hamstring injury subgroups when assessed in absolute or relative terms.ConclusionsAFL players that experienced a previous hamstring injury did not exhibit deficits in hamstring strength relative to their uninjured limb or players without a previous hamstring injury.     

Predictors of hamstring injury at the elite level of Australian football

BACKGROUND: Hamstring injuries are the most common injury sustained by elite Australian football players and result in substantial costs because of missed training time, unavailability for matches and lost player payments. Evidence to support proposed risk factors for hamstring injury is generally lacking, limiting the development of appropriate prevention strategies. AIM: To identify intrinsic risk factors for hamstring injury at the elite level of Australian football. METHODS: A prospective cohort of 222 players underwent baseline measurement in the form of a self-report questionnaire and a musculo-skeletal screen during the pre-season period of the 2002 Australian football season. Injury surveillance and exposure data were collected for the full season. Logistic regression analyses were used to identify independent predictors of hamstring injury in this group of players. RESULTS: Thirty-one players sustained a hamstring injury. A past history (previous 12 months) of hamstring injury and increasing age were found to be independent predictors of hamstring injury. CONCLUSIONS: Older players and those with a previous history of hamstring injury are target groups for further research and implementation of injury prevention strategies. Restricted ankle dorsiflexion range of movement warrants consideration in the development of prevention programs for hamstring injury.     

Allograft reconstruction for symptomatic chronic complete proximal hamstring tendon avulsion

Complete proximal hamstring tendon avulsion is an uncommon injury that can cause significant disability in young, athletic individuals. Surgical reattachment is recommended and can be performed on a delayed basis if the tissue is sufficiently mobile. We report 2-year follow up for two cases where interpositional allograft tissue was used for reconstruction because the tendon was too retracted for primary repair. Two 30-year-old patients with complete proximal hamstring avulsion at least 2 years earlier reported severe hamstring weakness and restrictions with respect to sport and recreational activities. Proximal hamstring tendon reconstruction with Achilles tendon allograft was performed for both patients. They were immobilized for 8 weeks with the hip in extension and the knee in flexion using a custom orthosis, followed by physical therapy and weight bearing as tolerated. The patients were followed for over 2 years after the surgery and were evaluated with physical examination, isokinetic strength testing and detailed questions about their function. Following the procedure, both patients returned to a more active lifestyle that was greatly improved with respect to participation in sport and function. This procedure should be considered as a salvage operation as the patients did not return to completely normal function and demonstrated hamstring weakness on the operated side.     

Increasing hamstring flexibility decreases lower extremity overuse injuries in military basic trainees

The purpose of this intervention study was to prove that increasing flexibility of the hamstring musculotendinous unit would decrease the number of lower extremity overuse injuries that occur in military infantry basic trainees. Two different companies going through basic training at the same time were used. Hamstring flexibility was checked at the beginning and at the end of the 13-week infantry basic training course. The control company (N = 148) proceeded through normal basic training. The intervention company (N = 150) followed the same program but added three hamstring stretching sessions to their already scheduled fitness program. All subsequent lower extremity overuse injuries were recorded through the troop medical clinic. Hamstring flexibility increased significantly in the intervention group compared with the control group. The number of injuries was also significantly lower in the intervention group. Forty-three injuries occurred in the control group for an incidence rate of 29.1%, compared with 25 injuries in the intervention group for an incidence rate of 16.7%. Thus, in this study, the number of lower extremity overuse injuries was significantly lower infantry basic trainees with increased hamstring flexibility.     

Surgical treatment of partial tears of the proximal origin of the hamstring muscles

Background

Hamstring injuries are common especially in athletes. Partial and complete tears of the proximal origin may cause pain and functional loss.

Objective

To evaluate the results of surgical treatment for partial proximal hamstring tears.

Methods

Between 1994 and 2005, 47 athletes (48 cases, 1 bilateral) with partial proximal hamstring tears were operated on. The cases were retrospectively analysed. Before surgery, 42 of the patients had undergone conservative treatment with unsatisfactory results, whereas in five patients the operation was performed within four weeks of the injury.

Results

The mean length of the follow up was 36 months (range 6–72). The result of the operation was rated excellent in 33 cases, good in nine, fair in four, and poor in two. Forty one patients were able to return to their former level of sport after an average of five months (range 1–12).

Conclusion

In most cases, excellent or good results can be expected after surgical repair of partial proximal hamstring tears even after conservative treatment has failed.     

Treatment for ischial tuberosity avulsion fractures in adolescent athletes

Purpose

Avulsion fractures of the ischial tuberosity are rare sports injuries typically occurring in young athletes. Their misdiagnosis may lead to chronic pain or disability. The aim of this study is to report a retrospective series of patients sustaining a fracture of the ischial tuberosity and to propose decision guidelines.

Methods

The mechanism of accident, the diagnostic management, the mode of treatment and outcome after avulsion fractures of the ischial tuberosity in adolescents were analysed.

Results

Thirteen patients (1 female and 12 males) with a median age of 15 years (range 13–16 years) with an avulsion fracture of the ischial tuberosity were included. Twelve of these patients suffered from sports injuries leading to the avulsion fracture. Five of our patients with a displacement of >15 mm were treated operatively. The outcome was excellent in cases of acute presentation and osteosynthesis. Eight patients were treated conservatively: four of them showed a displacement of <15 mm and had an excellent outcome; and the other four patients had a displacement of >15 mm. Two of those patients had excellent outcome with regular bone healing, the remaining two patients developed pseudarthrosis associated with a good outcome.

Conclusion

The present paper shows that in patients with displacement of <15 mm, conservative treatment yields excellent results and early operative intervention should be considered in physically active patients with displacement of >15 mm.

Level of evidence

IV.     

Spontaneous complete hamstring avulsion causing posterior thigh compartment syndrome

Complete avulsion of the hamstring muscle group from its ischial origin is an uncommon condition, and has been mostly reported in young athletes. A case is presented in which a middle aged man sustained this injury and developed a compartment syndrome of the thigh, which has not been previously reported. The surgical management of this patient is described.