Hamstring injuries of the hip

Hamstring injuries can be classified with regard to the site of involvement. Traumatic disorders at the proximal bone-tendon origin are best defined as avulsion injuries, such as ischial tuberosity fractures and hamstring tendon tears. Musculotendinous lesions include muscle strains and muscle contusions. Most hamstring injuries occur after in-direct trauma from excessive stretching or forceful contraction, leading to avulsion injuries or muscle strains and tears. Insufficient warm-up, lack of flexibility, inadequate muscle strength and endurance, or abnormal contraction and running may predispose to such injuries. In the event of blunt direct trauma, a muscle contusion, intramuscular hematoma, myositis ossificans, or compartment syndrome may develop.     

Point-of-Care Ultrasound Diagnosis of Proximal Hamstring Rupture

Background

Acute proximal hamstring ruptures can be a diagnostic challenge in the emergency department. The revealing sign of large posterior thigh ecchymosis is typically not yet present; the physical examination is limited due to pain, radiographs can be unremarkable, and definitive testing with magnetic resonance imaging is not practical. These avulsions are often misdiagnosed as hamstring strains and treated conservatively. The diagnosis is made after failed treatment, often months after the injury. Surgical repair at that time can be technically challenging and higher risk due to tendon retraction and adhesion of the tendon stump to the sciatic nerve.

Traumatic and overuse injuries of the ischial origin of the hamstrings

Purpose. Both acute and chronic hamstring injuries are disabling injuries, and occur almost entirely to elite athletes. We report our experience in the management of injuries of this location.

Methods. Twenty-seven patients (29 injuries) were included in the present study. They completed a questionnaire detailing their pre-injury activity, injury mechanism, rehabilitation and a subjective assessment of their recovery. At clinical examination, pain and hip motion were evaluated.

Results. Hamstring injuries predominantly affect males on the left side. Most procedures carried out were explorations with limited debridement and suture of the tendon. Thirty percent of patients felt they had returned to 100% of their pre-injury level, and 33% felt they had returned to 80 – 90% of their pre-injury level, the rest varied between less than 20% to 80%. Forty-five percent gave a value of zero on the visual analogue pain scale independent of activity. Those who gave a value above this had pain during active sports but not at rest.

Conclusion. Early repair leads to acceptable recovery of muscle function, especially when dealing with complete avulsions. Lesions to the origin of the hamstring can be successfully managed if a high suspicion for the condition is exerted.     

Rupture du tendon distal du biceps fémoral au FC Girondins-de-Bordeaux

Background

Hamstring muscle injury is a usual disorder for any athlete. However, distal rupture of the biceps femoris is a rare and unknown disorder. Some clinical studies have been published and show that a surgical treatment appears to be more efficient than a conservative treatment (as done for proximal hamstring injuries). The purpose of this case report is to disclose the functional outcomes of a professional football player after a surgical treatment.

Influence of bone mineral density, age, and strain rate on the failure mode of human Achilles tendons.

OBJECTIVE: To examine the influence of strain rate, bone mineral density, and age in determining the mode by which human Achilles tendons fail. DESIGN: Dual-energy X-ray absorptiometry and mechanical testing of excised Achilles tendon-calcaneus specimens. BACKGROUND: The Achilles tendon can fail by tendon rupture or bony avulsion. These injuries are caused by similar loading mechanisms and can present similar symptoms. It is important to understand when each mode of injury is likely to occur so that accurate diagnoses can be made and appropriate treatments selected. METHODS: Excised human Achilles tendons were loaded to failure at strain rates of 1% s(-1) and 10% s(-1) following dual-energy X-ray absorptiometry examination to determine bone mineral density near the tendon insertion. Calcaneal bone mineral density, donor age, and strain rate were compared between specimens that failed by avulsion and those that failed by tendon rupture. RESULTS: While strain rate was not observed to affect failure mode, the calcaneal bone mineral density of specimens that failed by avulsion was significantly lower than the bone mineral density of specimens that failed by tendon rupture (P=0.004). There was a significant decrease in bone mineral density with age (P=0.004), and the difference in age between the avulsed and ruptured specimens was close to statistical significance (P=0.058). For the avulsed specimens, there was a significant linear relationship between failure load and bone mineral density squared (P=0.002). Logistic regression indicated that the effect of age on failure mode is secondary to the primary effect of bone mineral density. CONCLUSIONS: The avulsions were primarily "premature" failures associated with low bone mineral density. Since bone mineral density decreases with age, older individuals are more likely to experience avulsions while younger individuals are more likely to experience tendon ruptures.     

Rupture haute des tendons ischiojambiers chez le sportif. À propos d'une série de neuf cas opérés

Objectives

Muscular pathology of the hamstring is frequent among athletes. On the other hand, complete rupture with avulsion at the proximal bone-tendon junction is a rare injury. Functional treatment of this injury gives no successful results. This study aims at providing information on the results of operations on 9 athletes.

Methods

Between 2002 and 2006, 9 male patients with an average age of 36.4 years (from 20 to 59) were operated on for a complete rupture of the hamstring at the proximal bone tendon junction due to sporting accidents — 4 rugby accidents, two soccer, one fencing and one aikido accident — and one domestic accident. Emergency magnetic resonance imaging was systematically employed. All nine were operated on using the same technique: by reinserting the tendons into the bone with several Mitek GII^® anchors (3.6 on average). A specific rehabilitation programme was set up. An isokinetic Biodex™test was done after 6 months.

Results

All 9 patients were reviewed after a mean period of 33 months (from 9 to 64). At the last review, all patients were satisfied with their functional results. Eight patients out of 9 had gone back to their sporting activities at the same level, a mean 5 months after the operation (from 4 to 7 months). The isokinetic tests related to the unimpaired member show a muscular deficit of less than 8% after the 6th month.

Conclusion

Complete rupture of the hamstring at the proximal bone tendon junction is a rare but serious injury. With an early diagnosis and rapid surgical treatment, normal functions can be recuperated with a rapid return to high level sporting activity.     

Diagnosis of Simultaneous Acute Ruptures of the Anterior Cruciate Ligament and Posterior Cruciate Ligament Using Point-of-Care Ultrasound in the Emergency Department

Background

Patients with acute anterior cruciate ligament (ACL) and posterior cruciate ligament (PCL) injuries from sport-related activities are frequently seen in the emergency department (ED). However, knee instability tests are known to show variable sensitivity and specificity. These tests would also have limited functionality in patients with severe pain and swelling in the knee.

Spinal manual therapy and exercises for chronic hamstring injuries in a sprinter: A case report

IntroductionHamstring injuries tend to be chronic in nature and thus require considerable recovery time in athletes. Although some rehabilitation protocols have been previously advocated, there is no consensus in terms of the treatment protocol for chronic hamstring injuries.MethodsWe present the case of a 15-year-old male sprinter who was successfully treated with a combination of manual therapy targeting the lumbosacral region and hamstring-specific exercises. The patient presented with hamstring pain which persisted for 7 weeks.ResultsManual therapy immediately reduced pain and increased muscle strength. The patient was able to run satisfactorily without pain 30 days after the initial intervention.ConclusionsThis case report suggests that the use of manual therapy targeting the lumbosacral region, along with hamstring exercises, may be beneficial in chronic hamstring pain management.     

Cross-sectional Study of EMG and EMG Rise During Fast and Slow Hamstring Exercises

BackgroundHamstring injuries remain a major burden in football while the effective prevention exercise the Nordic Hamstring is poorly adopted, despite the added positive effects on performance. Better understanding of hamstring function during Nordic Hamstring compared to other exercises may provide better insight to the physiological adaptations of different types of hamstring curls.PurposeThis cross-sectional study therefore aimed to compare the Nordic Hamstring curl with a conventional prone Leg Curl at different loads, and novel high velocity Hamstring Catches; in terms of peak normalized electromyographical activity (nEMG) and rate of electromyographic rise (RER) of Biceps Femoris long head, and angular velocity of the knee.Study designCross-sectional study.MethodsOut of 28 participants enrolled, the final sample included 23 recreationally active male participants who attended a session for determining RM (repetition maximum) to establish loading (8 and 16RM for Hamstring Catches, and 8, 16 and 24RM for Leg Curl) and to familiarize themselves with the three different exercises (Nordic Hamstring, Leg Curl and Hamstring Catch), and a testing session >4 days after during which EMG data were collected during 3 repetitions of each exercise performed in a random order.ResultsThe Nordic Hamstring evoked higher RER (1091.8 nEMG/s) than Hamstring Catches (mean difference: 421 nEMG/s, p<0.0001) and Leg Curl (mean difference: 705 nEMG/s, p<0.001), and at the earliest numerical timepoint from onset of muscle contraction (the Nordic Hamstring: 6 ms; Hamstring Catches: 36-41 ms; Leg Curl: 12-14 ms). Hamstring Catches displayed high peak angular velocity (mean: 471°/s). There was no difference in peak nEMG, irrespective of load for Leg Curl (8, 16 or 24RM) or Hamstring Catches (8- or 16RM).ConclusionThe Nordic Hamstring displayed the highest level muscle activity and most explosive recruitment characteristics with early and high rate of electromyographic rise, compared to even high velocity exercises, thus providing a possible mechanism by which it may increase performance and reduce injuries.Levels of evidence3What is known about the subjectEarly phase force and muscle recruitment have been linked to both performance and hamstring-related inhibition and fatiguability. However, the potential for different hamstring exercises to elicit explosive recruitment is unknown.What this study adds to existing knowledgeEarly phase recruitment was higher and faster during the Nordic Hamstring exercise compared with conventional hamstring Leg Curl exercises with different loads and a high-velocity hamstring exercise.Clinical RelevanceThe surprisingly fast and explosive recruitment characteristics during the Nordic Hamstring exercise suggests the possibility that this exercise have the potential to improve the rate of force development and perhaps counter the effects of hamstring-related inhibition and fatigue.     

Retour au sport après traitement chirurgical des ruptures proximales des tendons ischiojambiers : revue de la littérature

Objective

Rupture of the proximal hamstring tendons is a rare and little known injury. However, several studies have been published in recent years. A systematic review of the literature was performed according to a strict review protocol and whose main objective was the rate of return to sport after treatment.

Method

An electronically search was performed in Medline. The last search was conducted on 15 February 2013. In addition, the references of the selected articles were hand-searched for relevant citations. The inclusion criteria were studies in English or French, for acute or chronic ruptures of the proximal hamstring tendons, level of evidence 1–4 and related clinical outcomes of at least five patients. Exclusion criteria were literature reviews, expert opinions and non-clinical studies. The primary endpoint was the return to sport (yes/no).

Results

Seventeen studies published between 1995 and 2012 were included in the analysis. The total number of patients was 406, 393 underwent surgical repair and 13 were treated by conservative treatment. The rate of return to sport was reported in 16 studies. For conservative treatment, 58% of patients returned to sports with 25% to a level equivalent to prior trauma. For the surgical treatment, the average was 82.9% (69.6–100) with 81.3% (55–100) at the same level. The average time to return to sport was 6.3 (1–36) months.

Conclusion

Surgical repair of the proximal hamstring ruptures has significantly improved the functional outcomes of patients but it remains a serious condition that can compromise their sporting future.     

Strength assessment after proximal hamstring rupture: A critical review and analysis

BackgroundMuscular strength should be one of the main parameters to assess the interest or not of surgery after proximal hamstring rupture. Yet, this parameter is difficult to compare between the different studies because of the heterogeneous assessment methods.MethodsWe realized a critical review of strength assessment methods used to evaluate treatments performed after proximal hamstring rupture. The studies were selected from several medical databases with the keywords: “proximal hamstring rupture” OR “proximal hamstring avulsion” AND “strength” OR “isokinetic”.Findings24 articles evaluated muscular strength after proximal hamstring rupture. 7 have been excluded because the method was not described. 6 types of dynamometric evaluation were used: 2 with an isometric method, 3 with a pneumatic isotonic method and 13 with an isokinetic method. Muscular strengths after non-surgical treatment could not be compared because of the low number of studies and different methods of assessment. After surgery, only isokinetic results measured at the angular speed of 60°/s could have been weighted. A 15% strength deficit was shown at >12 months after surgery.InterpretationMuscular strength assessment methods currently used to evaluate the strength after proximal hamstring rupture are too disparate to clearly define the strength deficit after rupture and surgery. Strength evaluation should be more rigorous in order to prove the real interest of the surgical management.     

Incidence and outcome of rupture of the Achilles tendon

We determined the incidence of complete rupture of the Achilles tendon in the Maribor region (273,609 inhabitants) between 1991 and 1996. During this period, 116 ruptures were treated at Maribor Teaching Hospital. The average incidence was 7 ruptures per 100,000 inhabitants, with a peak incidence of almost 9 per 100,000. Most injuries (65%) occurred during sports activities, with soccer as the major cause of rupture. The average age of patients was 37 years with a male-to-female ratio of 18:1. All patients underwent open surgical repair of the ruptured Achilles tendon, with a minimum follow-up of two years. 19.8% of cases developed complications and in 10.4% of these the complications were major. 1.9% of patients sustained a re-rupture. The mean AOFAS score was 96 points. The patients were subjectively very satisfied with their treatment in 88% of cases. Good functional results with a return to the usual pre-injury activities were achieved in 96% of patients.     

Ultrasound Features of the Proximal Hamstring Muscle‐Tendon‐Bone Unit

The hamstring muscle complex is made by a group of posterior biarticular thigh muscles, originating at the ischial tuberosity, which extend the hip and flex the knee joint. Proximal hamstring injuries are frequent among athletes, commonly involving their long myotendinous junction during an eccentric contraction. In this pictorial essay, we describe the ultrasound technique to visualize the normal anatomy of the proximal hamstring muscle‐tendon‐bone complex and present ultrasound findings in patients with traumatic injuries and tendinopathies.     

Influence of graft type on sagittal plane knee biomechanics during stair ambulation following anterior cruciate ligament reconstruction

BackgroundBoth graft type and surgical technique for anterior cruciate ligament reconstruction can affect knee biomechanics. Several studies reported the influence of graft type, but few have controlled the surgical technique and fully investigated stair ambulation. This study aimed to compare knee biomechanics during stair ambulation between patients treated with hamstring tendon graft and those treated with patellar tendon graft when anterior medial portal technique was used to drill femoral tunnel.MethodsTwo groups of patients (patellar tendon, n = 18; hamstring tendon, n = 18) at average 12 months after reconstruction surgery were recruited to ascend and descend a customized staircase in a gait lab. Joint kinematics and kinetics were calculated for both operated and contralateral intact limbs based on kinematic analysis and inverse dynamics. The influence of graft type on knee flexion angle and moment was identified using one-way mixed (graft type and limb side) analysis of variance with post-hoc paired t-test.FindingsSignificant interaction between graft and limb was found for knee flexion and range of motion. Only the hamstring tendon group had significant kinematic deficits on the operated limb than the contralateral limb during stair ascent and descent. No significant interaction was found for knee flexion moment. Both graft groups had significant deficits in peak knee flexion moment on the operated side during stair ascent and descent.InterpretationWhile the choice of graft type does not affect the restoration of knee dynamic loading, patellar tendon graft better restores knee flexion-extension kinematics during stair ambulation.     

The Effects of Hamstring Stretching on Leg Rotation during Knee Extension

[Purpose] This study investigated the effects of hamstring stretching on leg rotation during active knee extension. [Subjects] Subjects were 100 bilateral legs of 50 healthy women without articular disease. [Methods] Hamstring hardness, leg rotation and muscle activities of the knee extensors during active knee extension were measured before and after hamstring stretching. [Results] Hamstring hardness was significantly decreased after hamstring stretching. The leg rotation angle, variation in leg rotation angle, variation in leg external rotation angle, and muscle activities of the vastus lateralis and rectus femoris were significantly increased after hamstring stretching. A moderate positive correlation was found between variation in leg rotation and variation in muscle hardness in hamstring. [Conclusion] Leg rotation during active knee extension was increased by hamstring stretching. Hamstring stretching would be effective as a pretreatment for restoring proper leg rotation when knee extension is conducted as a therapeutic exercise.Key words: Hamstring stretching, Leg rotation     

全层输尿管撕脱伤处理并文献复习（附4例报告）

【目的】探讨输尿管全层撕脱伤的诊治措施。【方法】2003年11月至2008年3月本院收治输尿管撕脱伤患者4例,其中1例输尿管肾盂撕脱行输尿管肾盂吻合术＋大网膜外面包裹;1例近端输尿管撕脱伤者行自体肾移植术;另2例远端输尿管撕脱伤患者行输尿管-膀胱吻合术。随访16～45个月,平均29个月。【结果】1例行自体肾移植术、输尿管膀胱吻合术后患者及2例行输尿管膀胱吻合术患者肾功能恢复良好;1例行输尿管-肾盂吻合术患者出现肾积水、肾脏无功能,行肾切除术。【结论】输尿管全层撕脱伤是罕见但严重的并发症,自体肾移植及输尿管膀胱吻合术可能是输尿管近段撕脱伤的理想治疗方法。     

高频超声诊断指伸肌腱滑脱的应用价值

目的 探讨高频超声在诊断指伸肌腱滑脱中的应用价值。方法 对32例掌指关节背侧外伤、临床疑诊指伸肌腱滑脱患者行高频超声检查,判断其指伸肌腱是否有滑脱及其原因,并与手术结果对照。结果 32例患者中,25例接受手术治疗,其中指伸肌腱部分滑脱7例、完全滑脱18例;7例无滑脱,仅腱帽挫伤,接受随访观察。高频超声漏诊1例指伸肌腱完全滑脱,将2例完全滑脱误诊为部分滑脱,与手术结果的一致性好（Kappa=0.85,P<0.01）。结论 高频超声可显示腱帽撕裂及指伸肌腱滑脱,能通过动态观察判断损伤程度,为临床治疗提供重要依据。     

Achilles tendon injuries

Purpose of review

The purpose of this study is to review the current literature of Achilles tendon injuries, specifically chronic tendinopathy and acute ruptures in regard to etiology, diagnosis, treatment options, and outcomes.

Recent findings

The incidence of Achilles tendon injuries is increasing, but the necessity for surgical intervention is decreasing due to improved conservative therapies, which may provide comparable outcomes without the implied surgical risk. If surgery is undertaken, no difference has been noted between open and minimally invasive techniques. The majority of patients are able to return to pre-injury level of activity, with the elite athlete as an unfortunate exception.

Summary

Achilles injuries can be devastating injuries, but if addressed early and appropriately, most patients have good self-reported long-term outcomes regardless of the treatment modality implemented. Further research is needed into the etiology, potential preventative measures, and longer-term outcomes of the different treatment options for wide range of Achilles pathology.