Posterior Thigh Injury-Tennis

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HISTORY: A 76-year-old male was sprinting for the ball one hour into playing singles tennis with a score of 6-6 when he developed acute onset right posterior mid-thigh pain. He denied an audible “pop.” He stopped playing, took ibuprofen, and applied ice upon returning home. He continued to rest and apply ice. Eight days later, he presented to the outpatient sports medicine clinic with improved pain rated 1-2/10, but with worsened swelling and bruising of the right distal posterior thigh. He denied back pain, hip pain, lower extremity numbness, tingling, or weakness. He denied a history of prior hamstring injury. He typically plays doubles tennis three times/week for two hours at a time. This was his second time playing singles this year. PHYSICAL EXAMINATION: Examination revealed bruising along the popliteal fossa and distal hamstring on the right. There was palpable swelling and mild tenderness along the medial aspect of the posterior mid-thigh on the right. There was no tenderness to palpation of the ischial tuberosity. Knee flexion strength was 4/5 on the right, 5/5 on the left. Gait was non-antalgic. There was pain with resisted right knee flexion at 135 degrees, with lesser discomfort at 90 and 45 degrees. Bilateral lower extremities were warm with intact sensation and +2 patellar and achilles reflexes. DIFFERENTIAL DIAGNOSIS: 1. Hamstring muscle strain or tear 2. Hamstring tendon avulsion injury 3. Femoral stress fracture 4. Adductor magnus strain 5. Referred pain from the lumbosacral spine, hip joint, or sacroiliac joint 6. Ischial bursitis TESTS AND RESULTS: Right Hamstring Ultrasound: -Hypoechogenicity of the right semimembranosus muscle consistent with partial tear -Intramuscular calcification in the area of the tear MRI Pelvis Without Contrast: -Suggestion of grade 2 hamstring muscle strain centered near the central myotendinous complex of one of the hamstring tendons, likely the semimembranosus FINAL WORKING DIAGNOSIS: Partial tear of the semimembranosus muscle with calcification TREATMENT AND OUTCOMES: 1. Rest for 2 weeks post-injury. 2. Walk and cycle if tolerated 3-4 weeks post-injury. No tennis. 3. Started physical therapy 4 weeks post-injury for progressive hamstring strengthening and return to tennis and exercise.