Return to Pre-Injury Level of Sport in an Elite Age-Group Triathlete after Non-Operative Treatment of Combined Complete Obturator Internus and Partial Hamstring Tendon Tears

Abstract

Introduction Proximal hamstring tendon tears are uncommon injuries. Currently there is no consensus on what constitutes optimum management but the literature demonstrates a recent trend towards surgical management. Several authors have demonstrated less long-term disability and better return to sporting activity with surgical treatment when compared to non-operative treatment. However, these reports have focused on complete tears and there is a dearth of evidence to guide management of partial tears particularly in the high performance athlete. Complete tear of the obturator internus tendon has rarely been described in the literature and has not been reported in combination with proximal hamstring tendon pathology. Case description A 58-year-old female elite age-group triathlete presented with an acute on chronic exacerbation of increasing right buttock pain that had reduced her mobility such that she was unable to continue sports participation or walk unaided. Examination revealed ischial tuberosity tenderness, reduced hamstring strength and pain on hip extension. Magnetic resonance imaging revealed a 25% partial thickness tear of the conjoined hamstring tendon and complete tear of the obturator internus. In the absence of a history of trauma and no underlying osseous abnormality, the aetiology of the injury was presumed to be related to overuse and her high training load. Results and conclusions Surgical management was considered due to the considerable disability and duration of symptoms. However, repair of the partial tear would require conversion to a full tear to repair the deep fibres and surgical management of obturator internus rupture has not previously been described. Ultrasound guided steroid injection to the ischial tuberosity and physiotherapy was performed as lower risk initial options. The patient experienced immediate relief of symptoms, and this improvement is maintained at latest follow-up (12 months). There was no significant difference between the pre-injury and latest SF36 and proximal hamstring questionnaire scores and she has returned to the pre-injury level of long distance cycling but has been unable to return to running Take-home message This case report describes an injury pattern not previously described (complete rupture of obturator internus and partial tear of hamstring tendons). This case report is therefore important in demonstrating that this injury pattern can allow return to non-impact pre-injury level of sport when treated non-operatively. The case report also has broader applicability to isolated partial hamstring tendon ruptures, which occur more frequently, but have a limited evidence base to guide management. This report highlights that despite an increasing trend towards surgical management of hamstring tendon tears, patients with partial tears treated with injection and physiotherapy have the potential to return to athletic performance.