A systematic review of surgical intervention in the treatment of hamstring tendon ruptures: current evidence on the impact on patient outcomes

Hamstring injuries are among the most common muscle injuries. They have been reported in many different sports, such as running, soccer, track and field, rugby, and waterskiing. However, they are also present among the general population. Most hamstring injuries are mild strains, but also moderate and severe injuries occur. Hamstring injuries usually occur in rapid movements involving eccentric demands of the posterior thigh. Sprinting has been found to mainly affect the isolated proximal biceps femoris, whereas stretching-type injuries most often involve an isolated proximal injury of the semimembranosus muscle. The main cause of severe 2- or 3-tendon avulsion is a rapid forceful hip flexion with the ipsilateral knee extended. Most hamstring injuries are treated non-surgically with good results. However, there are also clear indications for surgical treatment, such as severe 2- or 3-tendon avulsions. In athletes, more aggressive recommendations concerning surgical treatment can be found. For a professional athlete, a proximal isolated tendon avulsion with clear retraction should be treated operatively regardless of the injured tendon. Surgical treatment has been found to have good results in severe injuries, especially if the avulsion injury is repaired in acute phase. In chronic hamstring injuries and recurring ruptures, the anatomical apposition of the retracted muscles is more difficult to be achieved. This review article analyses the outcomes of surgical treatment of hamstring ruptures. The present study confirms the previous knowledge that surgical treatment of hamstring tendon injuries causes good results with high satisfaction rates, both in complete and partial avulsions. Early surgical repair leads to better functional results with lower complication rates, especially in complete avulsions.

KEY MESSAGEs

• Surgical treatment of hamstring tendon ruptures leads to high satisfaction and return to sport rates.
• Both complete and partial hamstring tendon ruptures have better results after acute surgical repair, when compared to cases treated surgically later.
• Athletes with hamstring tendon ruptures should be treated more aggressively with operative methods.

     

Elbow pain

Nonarticular causes of elbow pain include muscle strains, ligamentous injuries, epicondylitis, olecranon bursitis, and compressive neuropathies. Overuse and trauma commonly cause these conditions. The history and physical examination differentiate them from an intra-articular process such as synovitis. Laboratory analysis of fluid aspirated from a swollen olecranon bursa is necessary to differentiate infection or gout. X-rays are useful in avulsion fracture, osteochondritis dissecans, and epiphyseal separation. Electromyography with nerve conduction velocities can localize the site of nerve entrapment. Treatment, in general, consists of prevention from further overuse, protection by rest and splinting to allow healing, pharmacologic intervention to reduce inflammation, relieve pain and combat infection, and physical therapy to restore motion and function. Surgery may be necessary to repair torn muscle, to release the wrist extensors in refractory lateral epicondylitis, and to decompress an entrapped nerve.     

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.     

Osseous and myotendinous injuries about the knee

Osseous injuries may be articular, extra-articular, or physeal, and may be related to direct trauma, avulsion forces, or chronic microtrauma. Muscle and tendon injuries about the knee may occur alone or in association with more significant osseous and ligament injuries. Radiographs or computed radiography images remain an important screening technique for patients who have suspected knee injuries. After initial radiographs, MR imaging has become the most common modality for detection and complete evaluation of osseous and soft-tissue injuries about the knee when those radiographs and other techniques do not demonstrate clearly the type and extent of injuries. This article focuses on the usefulness of MR imaging in the detection, classification, and management of bone, muscle, and tendon injuries of the knee.     

Les accidents des muscles ischiojambiers. Un comportement très excentrique

Acute hamstring muscle strains are common in sports and are often causing extended absence from training and competition. Hamstring strains occur in slow speed stretching exercises and primarily during activities with excentric contraction of hamstring. Rehabilitation can be divided into restoration of muscle structure, function, activity and comeback to sports training. We propose a rather strict progressive protocol for field retraining to minimize the risk of recurrence.     

Effects of the hold and relax-agonist contraction technique on recovery from delayed onset muscle soreness after exercise in healthy adults

[Purpose] This study was conducted to verify the effects of the hold relax-agonist contraction and passive straight leg raising techniques on muscle activity, fatigue, and range of motion of the hip joint after the induction of delayed onset muscle soreness in the hamstring muscle. [Subjects] Sixty subjects were randomly assigned to a hold relax-agonist contraction group and a passive straight leg raising group. [Methods] Subjects in the experimental group underwent hold relax-agonist contraction at the hamstring muscle, while subjects in the control group underwent passive straight leg raising at the hamstring muscle. [Results] Subjects in the hold relax-agonist contraction group showed a significant increase in hamstring muscle activity and hip joint angle and a significant decrease in muscle fatigue. In the passive straight leg raising group, the hip joint angle increased significantly after the intervention. In the hold relax-agonist contraction group, hamstring muscle activity increased significantly and muscle fatigue decreased significantly. [Conclusion] We conclude that the hold relax-agonist contraction technique may be beneficial for improving muscle activation and decreasing muscle fatigue.Key words: Delayed onset muscle soreness, Hold relax-agonist contraction, Passive straight leg raising     

Tissue Characterization of Puborectalis Muscle From 3-D Ultrasound

Pelvic floor (PF) muscles have the role of preventing pelvic organ descent. The puborectalis muscle (PRM), which is one of the female PF muscles, can be damaged during child delivery. This damage can potentially cause irreversible muscle trauma and even lead to an avulsion, which is disconnection of the muscle from its insertion point, the pubic bone. Ultrasound imaging allows diagnosis of such trauma based on comparison of geometric features of a damaged muscle with the geometric features of a healthy muscle. Although avulsion, which is considered severe damage, can be diagnosed, microdamage within the muscle itself leading to structural changes cannot be diagnosed by visual inspection through imaging only. Therefore, we developed a quantitative ultrasound tissue characterization method to obtain information on the state of the tissue of the PRM and the presence of microdamage in avulsed PRMs. The muscle was segmented as the region of interest (ROI) and further subdivided into six regions of interest (sub-ROIs). Mean echogenicity, entropy and shape parameter of the statistical distribution of gray values were analyzed on two of these sub-ROIs nearest to the bone. The regions nearest to the bones are also the most likely regions to exhibit damage in case of disconnection or avulsion. This analysis was performed for both the muscle at rest and the muscle in contraction. We found that, for PRMs with unilateral avulsion compared with undamaged PRMs, the mean echogenicity (p = 0.02) and shape parameter (p < 0.01) were higher, whereas the entropy was lower (p < 0.01). This method might be applicable to quantification of PRM damage within the muscle.     

Magnetic resonance imaging of the hip: sports-related injuries

Normal hip disorders do not account for a large proportion of exercise-related injuries, but they can pose a clinical dilemma because symptoms tend to be nonspecific. Conventional radiographs may demonstrate some causes of hip pain, such as stress fractures and degenerative joint disease. Magnetic resonance imaging (MRI) of the hip has proven valuable in the diagnosis of radiographically occult osseous abnormalities and periarticular soft-tissue disorders such as stress fractures, avulsion injuries, musculotendinous abnormalities, and bursitis. Conventional MRI has been less useful in the evaluation of intra-articular lesions, including acetabular labral tears, intra-articular loose bodies, and cartilage lesions. Visualization of intra-articular structures and their abnormalities can be improved by injection of diluted gadolinium, which distends the capsule and leaks into labral tears. This article focuses on the use of conventional radiography and MRI in recreational and professional athletes with painful hip joints. Where possible, MRI is compared with other diagnostic modalities such as bone scan and computed tomography.     

Role of magnetic resonance imaging in musculoskeletal trauma

The unique ability of magnetic resonance (MR) imaging to visualize injuries of bone, cartilage, bone marrow, and supporting soft tissue structure makes it ideally suited for the evaluation of musculoskeletal trauma. Magnetic resonance imaging also offers exquisitely detailed anatomical information on the musculoskeletal system. The widespread availability of MR imaging and the constantly improving technology make it the imaging modality of choice for the patients with a musculoskeletal trauma.This review discusses the role and applications of MR imaging for musculoskeletal trauma. It covers traumatic conditions of the musculoskeletal system, including hemarthrosis, lipohemarthrosis, stress fracture, occult fractures, cartilage injuries, the muscle and tendon trauma, avulsion injuries, extensor mechanism injuries, and traumatic conditions of joints.     

Hamstring muscle strain treated by mobilizing the sacroiliac joint

The purpose of this study was to compare the effectiveness of two types of treatment of hamstring muscle strains. Twenty patients with hamstring muscle strains were assigned randomly to an Experimental Group (n = 10) or a Control Group (n = 10). Peak torque production of the quadriceps femoris and hamstring muscles and hamstring muscle length were measured before and after treatment. The hamstring muscles of the Experimental and Control groups were treated with moist heat followed by passive stretching. The Experimental Group also received manipulation of the sacroiliac joint. The change in hamstring muscle peak torque was significantly greater for the Experimental Group than for the Control Group (p less than .005). No significant differences existed between the two groups in either quadriceps femoris muscle peak torque or hamstring muscle length. The results of this study suggest a relationship between sacroiliac joint dysfunction and hamstring muscle strain.     

First-aid algorithms in dental avulsion

Almost one fourth of traumatic dental injuries occur at schools or in their surroundings. Prevalence of tooth avulsion varies from 0.5% to 16% of all cases of dental trauma. Children with dental avulsion may seek help from school nurses so they should be able to provide first-aid treatment. However, many studies showed that the general level of knowledge of medical staff concerning tooth avulsion is unsatisfactory and that it could be improved by educational activities. This article attempts to give short algorithms of first-aid management of avulsed tooth.     

Offseason Workout Recommendations for Baseball Players

Purpose of ReviewOffseason training programs are crucial for the baseball athlete. Preparation for the competitive season should be carefully planned to allow long-term athletic success. The two goals of the offseason training program are to optimize performance and reduce injury risk. These goals can only be accomplished with an understanding of the unique physical demands of the sport, and how these demands relate to performance and injury. The purpose of this article is to review the unique demands of baseball training along with current strength and conditioning principles to optimize offseason training for the baseball athlete.Recent FindingsTraditional strength and conditioning programs used in other sports may not maximize the qualities necessary for optimal baseball performance. Traditional strength and conditioning exercises, such as squat and deadlift, primarily train sagittal plane movement while frontal and transverse plane movements are likely equally as important for baseball players. Biomechanical studies have shown that trunk rotation power has the largest influence on throwing velocity in pitchers. Programs should also be designed to reduce injury risk for common injuries. The most common injuries in baseball include hamstring strains, throwing arm injuries, paralumbar muscle strains, hip adductor strains, and oblique muscle strains.SummaryThis review describes the typical periodization phases of the offseason and provides a sample program outlining an offseason program for a professional baseball player from September through February.     

Interventions for preventing hamstring injuries: a systematic review

Objectives

To assess, by systematic review, the effects of interventions used for preventing hamstring injuries in physically active individuals.

Selection criteria

Randomised or quasi-randomised trials of interventions for preventing hamstring injuries were included, as were trials testing interventions for the prevention of lower limb injuries, provided that hamstring injuries were reported. Risk ratios (RRs) and 95% confidence intervals (95% CIs) were calculated for dichotomous variables and are reported for individual and pooled data.

Main results

Seven randomised controlled trials involving 1919 participants were included. Some trials were compromised by poor methodology, including lack of blinding and incomplete outcome data. Four trials, including 287 participants, examined interventions directly targeted at preventing hamstring injuries. Three of these trials, which tested hamstring strengthening protocols, had contradictory findings, with one small trial showing benefit, although the control rate of mainly minor hamstring injury was unusually high. The other two trials found no benefit, with a greater incidence of hamstring injury in the intervention group. One unpublished and underpowered trial provided some evidence that manual therapy may prevent lower limb muscle strain (RR 0.13, 95% CI 0.02 to 0.97), although the finding for hamstring injury did not reach statistical significance (RR 0.21, 95% CI 0.03 to 1.66).

Conclusions

There is insufficient evidence from randomised controlled trials to draw conclusions on the effectiveness of interventions used to prevent hamstring injuries in people participating in football or other high-risk activities. The findings for manual therapy need confirmation.     

Delayed post effort muscle soreness]

Muscle intolerance to exercise may result from different processes. Diagnosis involves confirming first the source of pain, then potential pathological myalgia. Delayed-onset muscle soreness (DOMS), commonly referred as tiredness, occurs frequently in sport. DOMS usually develops 12-48 h after intensive and/or unusual eccentric muscle action. Symptoms usually involve the quadriceps muscle group but may also affect the hamstring and triceps surae groups. The muscles are sensitive to palpation, contraction and passive stretch. Acidosis, muscle spasm and microlesions in both connective and muscle tissues may explain the symptoms. However, inflammation appears to be the most common explanation. Interestingly, there is strong evidence that the progression of the exercise-induced muscle injury proceeds no further in the absence of inflammation. Even though unpleasant, DOMS should not be considered as an indicator of muscle damage but, rather, a sign of the regenerative process, which is well known to contribute to the increased muscle mass. DOMS can be associated with decreased proprioception and range of motion, as well as maximal force and activation. DOMS disappears 2-10 days before complete functional recovery. This painless period is ripe for additional joint injuries. Similarly, if some treatments are well known to attenuate DOMS, none has been demonstrated to accelerate either structural or functional recovery. In terms of the role of the inflammatory process, these treatments might even delay overall recovery.     

Brachial plexus trauma: the morbidity of hemidiaphragmatic paralysis

Phrenic nerve palsy has previously been associated with brachial plexus root avulsion; severe unilateral phrenic nerve injury is not uncommonly associated with brachial plexus injury. Brachial plexus injuries can be traumatic (gunshot wounds, lacerations, stretch/contusion and avulsion injuries) or non-traumatic in aetiology (supraclavicular brachial plexus nerve block, subclavian vein catheterisation, cardiac surgeries, or obstetric complications such as birth palsy). Despite the known association, the incidence and morbidity of a phrenic nerve injury and hemidiaphragmatic paralysis associated with traumatic brachial plexus stretch injuries remains ill-defined. The incidence of an associated phrenic nerve injury with brachial plexus trauma ranges from 10% to 20%; however, because unilateral diaphragmatic paralysis often presents without symptoms at rest, a high number of phrenic nerve injuries are likely to be overlooked in the setting of brachial plexus injury. A case report is presented of a unilateral phrenic nerve injury associated with brachial plexus stretch injury presenting with a recalcitrant left lower lobe pneumonia.     

Mechanisms of increased passive compliance of hamstring muscle-tendon units after spinal cord injury

Background

People with spinal cord injury sometimes develop abnormally compliant hamstring muscle-tendon units. This study investigated whether the increased muscle-tendon compliance is due to a change in the passive properties of the muscle fascicles or tendons, or to muscle tears.

Methods

Semimembranosus muscle fascicle lengths were measured from ultrasound images obtained from 15 spinal cord injured subjects and 20 control subjects while the hip was passively flexed with the knee extended. Semimembranosus muscles of spinal cord injured subjects were inspected for tears using ultrasound imaging.

Findings

The mean (SD) hip angle at 30 Nm was 97 (SD 24) degrees in spinal cord injured subjects and 70 (SD 11) degrees in control subjects, indicating that spinal cord injured subjects had very compliant hamstring muscle-tendon units. The ratio of change in fascicle length to change in muscle-tendon length was not statistically different between spinal cord injured subjects and control subjects: muscle fascicles lengthened by 0.30 (SD 0.24) mm/mm in spinal cord injured subjects and 0.42 (SD 0.29) mm/mm in control subjects. These data were used to show that there was evidence of increased tendon compliance of spinal cord injured subjects compared to control subjects, but no evidence of increased muscle fascicle compliance. No tears were observed in semimembranosus muscles of spinal cord injured subjects.

Interpretation

The increased hamstring muscle-tendon compliance apparent in some spinal cord injured subjects is due, at least in part, to increased tendon compliance. There was no evidence that the increased muscle-tendon compliance was due to muscle tears.     

Eine folgenschwere Meniskusverletzung

Recently, meniscal root tears have gained increasing attention and correct diagnosis of these injuries can easily be missed on MR imaging as well as during diagnostic arthroscopy. These injuries are considered to be among the most serious meniscal lesions because the mechanical effects can be similar to a total meniscectomy. The integrity of the circumferential fibers is vital to the function of the meniscus, therefore repair of root tears should be considered although this can be technically demanding. There are several procedures described in the literature which are able to fully restore meniscal function in experimental settings and with good short-term clinical follow-up in a limited number of cases. We report on the case of a 52-year-old man with acute symptoms of medial meniscal injury after repeated distorsion trauma. MRI showed marked subluxation of the medial meniscus and compared to MRI imaging obtained 4?months before recent trauma, the root of the posterior horn of the medial meniscus could not be exactly visualized anymore. After performing posteromedial release a complete avulsion of the posterior root of the medial meniscus was detected during arthroscopy. Refixation to the anatomical footprint was performed by the use of a transtibial pull out suture which was passed through the posterior root via an additional posteromedial portal. Concerning the postoperative protocol it has to be emphasized that any axial force has to be avoided for 6 weeks to protect the reconstructed meniscal ring structure from being stressed. Unloaded flexion is limited to 90° for 6?weeks.     

Mechanisms and patterns of injury: the key to anticipation in trauma management

Traumatic injuries are classified into blunt and penetrating injuries. Penetrating injuries are caused when an object such as a knife or bullet crushes and tears the tissues that it traverses. The energy transfer from the penetrating object to the tissues determines the degree of injury, and the wounding tract determines the pattern of injury. Blunt trauma produces injury by transferring energy through acceleration forces (+ and -) to the victim (usually from motor vehicles or falls). The pattern and severity of injury are determined by the magnitude and orientation of the acceleration change to the victim's anatomy.     

The Effect of Theta Burst Stimulation Over the Primary Motor Cortex on Experimental Hamstring Pain: A Randomized,Controlled Study

Theta burst stimulation (TBS) over the primary motor cortex (M1) is an emerging technique that may have utility in the treatment of musculoskeletal pain. However, previous work exploring the analgesic effects of noninvasive brain stimulation has been limited largely to the arm or hand, despite 80% of acute musculoskeletal injuries occurring in the lower limb. This is a pertinent point, given the functional and neurophysiological differences between upper and lower limb musculature, as well as evidence suggesting that reorganization of corticomotor pathways is region-specific. This study investigated the effect of excitatory TBS on pain, function, and corticomotor organization during experimentally induced lower limb pain. Twenty-eight healthy participants attended 2 experimental sessions. On Day 0, participants completed 10 sets of 10 maximal eccentric contractions of the right hamstring muscles to induce delayed onset muscle soreness. Four consecutive blocks of either active or sham TBS were delivered on Day 2. Measures of mechanical sensitivity, pain (muscle soreness, pain intensity, pain area) function (single-leg hop distance, maximum voluntary isometric contraction, lower extremity functional scale), and corticomotor organization were recorded before and after TBS on Day 2. Pain and function were also assessed daily from Days 2 to 10. Active TBS reduced mechanical sensitivity compared to sham stimulation (P = .01). Corticomotor organization did not differ between groups, suggesting that improvements in mechanical sensitivity were not mediated by changes in M1. Subjective reports of pain intensity and function did not change following active TBS, contrasting previous reports in studies of the upper limb.PerspectiveM1 TBS reduces mechanical sensitivity associated with experimentally induced hamstring pain. Though further work is needed, these findings may hold important implications for those seeking to expedite recovery or reduce muscle sensitivity following hamstring injury.