Update on Evaluation and Management of Proximal Hamstring Tendon Injury in the Athlete

Background: Proximal full-thickness free hamstring tendon injury (ie, tendon avulsion or rupture) is a severe injury. Treatment decision making relies on clinical factors and magnetic resonance imaging (MRI) variables; it specifically relies on which tendons are injured as well as the extent of tendon retraction. According to a worldwide evaluation of current practice, discontinuity of both proximal tendons and retraction of >2 cm are used as surgical indications. However, both the diagnosis and the use of MRI variables in decision making may be fraught with uncertainty in clinical practice. A reliable standardized MRI assessment is required. Purpose: To propose an MRI assessment for acute proximal full-thickness free hamstring tendon injury and to evaluate its interater reliability. Study Design: Cohort study (diagnosis); Level of evidence, 2. Methods: We included 40 MRI scans of patients with acute (≤4 weeks of injury) proximal full-thickness free hamstring tendon injury. Three musculoskeletal radiologists assessed proximal full-thickness free hamstring tendon discontinuity using the novel “dropped ice cream sign” and tendon retraction (in mm). Quantification of tendon retraction (in mm) was performed using 2 different methods: (1) a direct (ie, shortest distance between the center of the hamstring origin and the tendon stump) method and (2) a combined craniocaudal/mediolateral measurement method. Absolute and relative interrater reliability were calculated. Results: We found an almost perfect interrater agreement (kappa = 0.87) for assessment of full-thickness tendon discontinuity using the dropped ice cream sign. Interrater agreement for the direct and craniocaudal retraction measurements was good for both the conjoint (intraclass correlation coefficient [ICC], 0.88 and 0.83) and the semimembranosus tendons (ICC, 0.81 and 0.79). The mediolateral retraction measurement yielded only moderate to poor reliability for the conjoint (ICC, 0.53) and semimembranosus tendons (ICC, 0.41). Conclusion: The standardized MRI assessment to identify proximal hamstring tendon discontinuity and quantify tendon retraction is reliable. We recommend using the novel dropped ice cream sign and the direct retraction measurement in clinical practice and research.

To evaluate the current evidence and literature on treatment options for proximal hamstring injuries. Patients with 3-tendon complete tears with greater than 2cm of retraction have worse outcomes and higher complication rates compared to those with less severe injuries. Endoscopic and open proximal hamstring repair both have favorable patient reported outcomes at 5-year follow up. Proximal hamstring repair in patients who are male, with isolated semimembranosus injury, and have proximal hamstring free tendon rupture are more likely to have earlier return to sports. The Parisian Hamstring Avulsion Score (PHAS) is a validated patient-reported outcome measure to predict return to sports. Proximal hamstring injuries may occur in both elite and recreational athletes and may present with varying degrees of chronicity and severity. Injuries occur most commonly during forceful eccentric contraction of the hamstrings and often present with ischial tuberosity tenderness, ecchymosis, and hamstring weakness. Treatment decision-making is dictated by the tendons involved and chronicity. Many proximal hamstring injuries can be successfully treated with non-surgical measures. However, operative treatment of appropriately indicated proximal hamstring tendon injuries can result in significantly better functional outcomes and faster and more reliable return to sports compared to nonoperative treatment. Both endoscopic and open surgical repair techniques show high satisfaction levels and excellent patient-reported outcomes at short- and mid-term follow-up. Postoperative rehabilitation protocols vary across the literature and ongoing study is needed to clarify the optimal program, though emphasis on eccentric hamstring strengthening may be beneficial.

Proximal hamstring tendon avulsions are a relatively common injury, occurring in both high level and recreational athletes. These injuries occur due to an eccentric load while the knee is extended, and hip is flexed. Management of proximal hamstring injuries is a current area of controversy. The literature has shown improved strength and return to pre-injury level of activity with surgical repair of these injuries, unfortunately this has been shown to be associated with complication rates of up to 23%. The aim of this study was to explore the clinical results following operative management of proximal hamstring tendon avulsions, in addition to assessing patient outcomes after surgical repair of these injuries. This was a single-site retrospective study of patients with surgically repaired proximal hamstring tendon avulsions between 2017 and 2022, with at least one year follow up. Patient demographics, mechanism of injury, surgical data and complications were collected. Patient strength was assessed by prone knee flexion compared to the contralateral normal side. Patient reported outcomes were also performed which included the Lower Extremity Function (LEF) score and International Hip Outcome Tool (iHOT) score at final follow up. The collected data was analyzed and P values of < 0 .05 were considered statistically significant. A total of 41 patients were included in the study with a mean age of 49.5±11.7 years. Of the cohort 58.5% were males with the most common mechanism of injury being skating/skiing (31.7%). A three-tendon injury was the most common entity (82.9%) and the majority were retracted at least 6cm (51.2%). A significant association was found between number of tendons injured and patient age, as single tendon injury mean age (30.7±13.4) was significantly younger than two and three tendon injuries (49±18.5 and 51.2±9.4, respectively, p < 0 .05). Concerning operative data, median time from injury to surgery was 22 days (IQR 16.5 to 35, range 7-153 days). Nearly all cases were fixed with suture anchors (95.1%) and three anchors was the most common number applied (46.2%). Of the cohort 12.2% had a complication (two of which were nerve injuries (neuropathic pain from posterior femoral cutaneous nerve), two were failure of repair and one was intractable pain requiring admission for pain control). The majority of patients regained full hamstring strength (87.8%) and returned to pre-injury activity levels (70.7%). Patient reported outcomes post-repair were excellent at final follow up, as mean LEFS was 93.6±15.9 and mean iHOT was 92.2±17.4. Patient reported outcomes were significantly associated with complications, return of full hamstring strength, return to baseline level of activity and patient satisfaction. Patients who have their proximal hamstring tendon avulsions repaired surgically can expect to regain pre-injury strength and level of activity with good patient reported outcomes and low rates of complications.

Background: Chronic incomplete proximal hamstring avulsion injuries are debilitating injuries associated with prolonged periods of convalescence and poor return to preinjury level of function. This study explores the efficacy of operative intervention for these injuries on patient satisfaction, muscle strength, range of motion, functional performance, return to preinjury level of sporting activity, and injury recurrence. Hypothesis: Surgical intervention of chronic incomplete proximal hamstring avulsion injuries enables return to preinjury level of sporting function with low risk of clinical recurrence. Study Design: Case series: Level of evidence, 4. Methods: This prospective single-surgeon study included 41 patients with incomplete proximal hamstring avulsion injuries refractory to 6 months of nonoperative treatment. All study patients underwent primary operative repair of the avulsed proximal hamstring tendon and received standardized postoperative rehabilitation. Predefined outcomes were recorded at regular intervals after surgery. Mean follow-up time was 28.2 months (range, 25.0-35.0 months) from date of surgery. Results: All patients returned to their preinjury level of sporting activity. Mean ± SD time from surgery to return to full sporting activity was 22.2 ± 6.7 weeks. There were no episodes of clinical recurrence. At 3 months after surgery, 39 patients (95.1%) were satisfied/very satisfied with the outcomes of their surgery, and as compared with preoperative values, improvements were recorded in isometric hamstring muscle strength at 0° (84.9% ± 10.9% vs 40.4% ± 8.8%; P < .001), 15° (89.6% ± 7.6% vs 44.2% ± 11.1%; P < .001), and 45° (94.1% ± 5.1% vs 66.4% ± 9.0%; P < .001); mean passive straight leg raise angle (71.2°± 13.5° vs 45.4°± 11.9°; P < .001); mean lower extremity functional score (70.9 ± 5.1 vs 48.4 ± 5.2; P < .001); and mean Marx activity rating score (5.6 ± 2.8 vs 2.7 ± 1.0; P < .001). High patient satisfaction and functional outcome scores were maintained at 1- and 2-year follow-up. Conclusion: Operative repair of chronic incomplete proximal hamstring avulsion injuries enabled return to preoperative level of sporting function with no episodes of clinical recurrence at short-term follow-up. Surgical intervention was associated with high patient satisfaction and improved isometric hamstring muscle strength, range of motion, and functional outcome scores as compared with preoperative values. High patient satisfaction and improved functional outcomes were sustained at 2-year follow-up.

The adductor longus has become recognized as one of the more commonly injured muscles in the medial compartment. Acute complete rupture injuries occurring at the proximal aspect of the muscle are less common. Limited data exist regarding management of the injuries in athletes required for return to play and functioning. The current data favors operative management; however, nonoperative treatment may be a viable option. Nonoperative management of avulsion injuries of the proximal adductor longus tendon may prove equal results to surgical repair in return to play and functioning. A semi-professional football player sustained a left groin injury while participating in the play. Due to continued pain, swelling, and suspicion of injury, a magnetic resonance imaging was performed diagnosing a complete tear of proximal adductor longus tendon. Physical examination, strength, and range of motion were recorded until the patient was able to function normally without strength deficit, the range of motion loss, and the return of speed. The player was treated nonoperatively and was eventually allowed to return to play. The time of return to play was 6 weeks. Strength deficit was not appreciated or loss of motion and player was able to return to baseline function. Nonoperative management of complete avulsion injuries of the proximal adductor longus tendon result in faster return to play than operative management even if significant retraction is present.

Objectives:Proximal hamstring tears are relatively uncommon injuries, but can lead to persistent pain and disability. Previous literature has described avulsion of all three proximal tendons, avulsion of two tendons with retraction of over 2 cm, and tendon avulsions with failure of non-operative management as indications for operative repair. Most previous studies have utilized post-operative protocols that include some form of brace immobilisation to restrict hip flexion and knee extension and/or a limited weight-bearing period. We hypothesize that proximal hamstring repair utilizing an accelerated rehabilitation protocol that allows full weight-bearing without immobilization immediately post-operative will result in similar outcomes to published series and that better results will be noted in acute repairs (surgery within 4 weeks of injury).Methods:Retrospective chart review identified 47 proximal hamstring tendon repairs in 43 patients performed at our institution between 2008 and 2015. Proximal hamstring tendon repair was carried out with suture anchors by a single sports medicine fellowship-trained orthopaedic surgeon. Post-operative rehabilitation included no immobilization or limited weightbearing. Patients were only instructed to avoid rapid walking for 6 weeks post-operative. Clinical history, radiographic findings, and surgical details were obtained from chart data. Patients were then contacted to by phone to assess outcomes following surgery utilizing the lower extremity functional score (LEFS), the single assessment numeric evaluation (SANE), and Marx activity scale. Complications and repair failures were also noted. Overall patient-reported scores were calculated and results of acute and chronic repairs were compared.Results:Thirty-four patients who underwent a total of 38 proximal hamstring repairs (80.8%) were available for follow-up via phone interview at a mean of 4.1 ± 2.0 years following proximal hamstring repair. There were two re-tears: one rupture at 5 weeks post-op and one partial rupture at 10 weeks post-op. Overall, patients reported high satisfaction with the procedure, with a mean LEFS score of 87± 21%, a mean SANE score of 88.1 ± 11.6, and a Median Marx activity score of 5. The acute repair group was noted to have a higher mean LEFS score (93.7 ± 11.1%) than the chronic repair group (79.8 ± 28.8%), p = 0.046. The average SANE score in the acute group (91.3 ± 8.3) was also significantly higher than in the chronic group (83.8 ± 14.3), p = 0.047. The median Marx Activity scale was similar in the acute (median = 5.5) and chronic (median = 5.0) groups (p = 0.88).Conclusion:Proximal hamstring tendon repair followed by post-operative rehabilitation that included no immobilization or limited weight bearing resulted in patient-reported outcomes scores and repair failure risk that were similar to previously published series that utilized more limiting post-operative protocols. Better patient-reported outcomes were noted in repairs performed within 4 weeks of injury.

Proximal hamstring tendon injuries occur frequently in the athletic population resulting in varying degrees of functional disability depending on severity of injury. The purpose of our case vignette is to describe a surgical technique and clinical outcome for open proximal hamstring tendon repair with a confirmed biomechanically sound construct. We also describe and summarize the current literature recommendations for proximal hamstring injuries. We present a case and surgical technique report on a 27-year-old male who suffered a proximal hamstring tendon rupture. Utilizing a double row all-knotless suture bridge construct with a total of four anchors and six suture limbs allowed for anatomic footprint coverage and strength. Two years of clinical follow-up was obtained evaluating hip and knee range of motion, strength, and functional ability. Our patient underwent uncomplicated open surgical repair and returned to all activity at four months following surgery. Range of motion and strength returned to preoperative levels at the four-month postoperative mark. The use of a reproducible double row all-knotless suture bridge technique provided adequate strength and stability in the setting of a proximal hamstring tendon rupture. Open and endoscopic surgical techniques performed acutely both show positive postoperative subjective outcomes as well as a high likelihood of returning to sport. Controversy remains present in regard to the repair technique as well as postoperative bracing and physical therapy recommendations.

Proximal hamstring tendon avulsions lead to a significant loss of strength and a functional deficit of the respective lower limb and surgery is the recommended treatment. Only little is known about the clinical outcomes and complications when comparing acute and chronic management as well as partial and complete tears. Therefore, the purpose of this study was to investigate the clinical results and the complication rate of patients after surgical treatment of proximal hamstring tendon injuries. It was hypothesized that surgical treatment of an acute proximal hamstring avulsion would lead to a superior clinical outcome with a low complication rate and high return to sports rate compared to chronic cases and partial avulsions. Patients who underwent proximal hamstring tendon repair between 2008 and 2015 were retrospectively evaluated with a minimum follow up of 2years. Outcome measurements were obtained by means of Lysholm score, Harris Hip Score, Visual Analog Scale, and Tegner Activity Scale. Return to sports (RTS) rate was determined. Postoperative adverse events were recorded and complications reported. Patients' outcomes were compared between acute/chronic repair and partial/complete injury patterns. Ninety-four of 120 (78.3%) were available for final assessment at a mean follow-up of 56.2 ± 27.2months. Clinical outcome measures were excellent and did not differ between the treatment groups or between the different injury patterns. RTS was achieved by 86.2% of the patients and was significantly superior after acute treatment (p < 0.05). The overall complication rate was 8.5% and significantly higher in complete tears compared to partial tears and in delay compared to acute surgery (p < 0.05). Surgical treatment of proximal hamstring tendon avulsions results in excellent clinical outcome scores and a high RTS rate. Open surgical treatment has shown to be a safe procedure with a low complication rate. Surgical timing is important, as early surgical intervention provides a higher RTS rate and a lower complication rate than delayed surgery and should therefore be preferred in clinical practice. Repair of partial and complete tears lead to similar clinical outcome, but a higher complication rate in complete avulsions. Level IV.

Background DVT remains a concern following repair of the proximal hamstring tendons, yet the rate of occurrence of this potential post-operative complication has not been previously characterized. The purpose of this study was to characterize the factors related to the development and treatment of DVTs following proximal hamstring repair. Methods A systematic literature review was conducted in accordance with PRISMA guidelines. PubMed and EMBASE were searched to identify studies from database origin to May 2022. Studies were included if they discussed proximal hamstring repair, postoperative outcomes for at least 6 months, patient demographics, number of tendons injured, occurrence of DVT postoperatively, and specified acute or chronic injury. A repeated search was performed in May 2023 and no further articles were identified. A total of 590 studies were identified, 8 of which (422 patients, 464 proximal hamstring repairs) met the inclusion criteria. Results From the 422 patients included in the study, there were a total of 426 injuries sustained. Of the 426 hamstring injuries, 222 (47.8%) were categorized as acute and 204 (44%) were chronic. Nine cases of DVT were identified in the postoperative period, which made up 2.1% (9/422) of the study population or 1.9% (9/464) of the surgical cases. Two of the nine (22.2%) DVTs occurred in patients undergoing repair for chronic proximal hamstring tendon ruptures. Three of nine (33.3%) DVTs occurred in patients who suffered a complete proximal hamstring tendon avulsion. Two of the nine (22.2%) occurred in patients with an acute, complete tear of the proximal hamstring tendon. For two of the DVTs, there was no information on the specific type of injury. All 9 DVTs occurred following an open surgical approach. Conclusion There is limited data available regarding the incidence of DVT following repair of proximal hamstring tendon injuries, as well as a lack of consistent protocols for post-operative DVT prophylaxis. Most DVTs occurred in patients with a complete proximal hamstring tendon avulsion. Further studies are needed to clearly define rate of DVT and investigate common postoperative protocols for DVT prophylaxis.

Background:Hamstring injuries are the leading cause of time lost in professional soccer. Among these, tendon-related lesions of the biceps femoris (BF) are associated with longer recovery and higher reinjury risk. Emerging magnetic resonance imaging (MRI) findings suggest the existence of morphological subtypes with different prognostic implications.Purpose:To describe an MRI pattern of proximal BF tendon injury—the “Bunny Tail lesion”—and report its management and outcomes in elite soccer players.Study Design:Case series; Level of evidence, 4.Methods:Over 2 competitive seasons (July 2023–June 2024), all acute hamstring injuries in a Serie A club were prospectively recorded and retrospectively reviewed. Players were eligible if MRI showed focal peritendinous edema at the distal tip of the proximal tendon of the BF long head, with increased intratendinous signal and preserved tendon continuity. Three musculoskeletal radiologists independently classified lesions using the British Athletics Muscle Injury Classification (BAMIC). Interobserver agreement was assessed with Fleiss κ. Rehabilitation followed a structured, football-specific program with standardized return-to-training and return-to-play (RTP) criteria.Results:Eight professional players met inclusion criteria. All lesions showed a well-circumscribed ovoid peritendinous edema surrounding the distal extremity of the proximal BF tendon, with preserved structural continuity. Lesions were variably categorized as BAMIC 2b to 2c, with one graded 3c by a single radiologist. Interobserver agreement for combined grade and tissue classification was very low [Fleiss κ close to 0]. All athletes were managed conservatively and returned to training after 14.6 ± 3.0 days and to play after 26 ± 6 days. No reinjuries occurred during a mean follow-up of 395 ± 202 days.Conclusion:This small series describes a consistent MRI pattern of proximal BF tendon injury characterized by focal ovoid peritendinous edema at the distal tendon tip, preserved continuity, and relatively rapid RTP despite predominantly tendinous BAMIC classification. This pattern may represent a less severe variant within the spectrum of proximal BF tendon injuries.

PurposeThis study aimed to compare the patient‐reported outcome score, return‐to‐sports rate, knee flexion strength and complications of operative and non‐operative treatments for proximal hamstring tendon avulsions.MethodsA comprehensive search of PubMed, Ovid and Scopus was conducted to identify clinical comparative studies with Levels 1–3 evidence on operative versus non‐operative management for proximal hamstring tendon avulsions. Studies were included if they reported post‐treatment clinical outcomes and met inclusion criteria: comparative design, English language, full‐text availability, and patient‐reported outcomes. Data were analyzed using odds ratios (ORs) for dichotomous outcomes and mean differences (MDs) for continuous outcomes, with heterogeneity assessed by chi‐square tests.ResultsSeven studies, encompassing 8 cohorts and 592 cases (256 operative, 109 non‐operative), met the inclusion criteria. The Methodology Index for Non‐Randomized Studies scores for these studies ranged from 14 to 22, indicating a fair to good methodological quality. The operative group demonstrated a statistically significantly higher return‐to‐sport rate at pre‐injury performance levels compared to non‐operative management (65.2% vs. 50.7%; OR = 1.83; p = 0.005). Pooled meta‐analyses revealed no statistically significant differences in post‐treatment patient‐reported outcomes, as measured by the Lower Extremity Functional Scale (MD = 2.32; 95% CI: −0.41 to 5.05; p = 0.10) and the Perth Hamstring Assessment Tool (MD = 0.37; 95% CI: −3.61 to 4.35; p = 0.86). Neurological complications, including sciatic nerve symptoms, were similar between the two groups.ConclusionBased on fair to good‐quality studies, findings apply mainly to active, middle‐aged recreational athletes. The operative and non‐operative treatments yield similar patient‐reported outcomes in proximal hamstring avulsions, though operative management may facilitate a higher return‐to‐sport rate.Level of EvidenceLevel III.

Increased Prevalence of Femoroacetabular Impingement in Patients With Proximal Hamstring Tendon Injuries

Diagnosis, Classification, and Management of Acute Proximal Hamstring Avulsion Injuries

The hamstring muscle complex comprises several biarticular posterior thigh muscles. These muscles originate from the ischial tuberosity and attach distally to the knee. Hamstring muscle injuries are among the most common in the lower extremities of active individuals. Hamstring injuries follow a consistent pattern and medical history, including a sudden, explosive movement (sprinting, kicking, jumping, or lunging). The onset of pain is usually acute in the proximal posterior aspect of the upper thigh. Injured individuals may describe a “pop” or “snap” or a sensation as if someone kicked them in the back of the thigh. An accurate diagnosis of proximal hamstring overuse, partial tears, or ruptures is essential for appropriate treatment planning and optimizing patient outcomes. Diagnostic musculoskeletal ultrasound (MSKUS) offers a portable, real-time, and cost-effective alternative, gaining traction in rehabilitation and sports medicine settings. MSKUS has emerged as a valuable, non-invasive imaging modality for evaluating proximal hamstring injuries, including tendinopathy, muscle strains (partial tears), and ruptures. MSKUS is excellent at detecting changes in tendon and muscle composition and continuity. This manuscript will review the utility of MSKUS in evaluating proximal hamstring tendon and muscle injury, including anatomy, common injury patterns, sonographic techniques, and clinical implications for rehabilitation professionals. By integrating MSKUS into clinical practice, providers can improve diagnostic accuracy, enhance diagnostic confidence, monitor healing progression, and guide rehabilitation strategies to achieve optimal patient outcomes for those with hamstring injuries.

The purpose of the present study was to validate a new scoring system for proximal hamstring injury-the Perth Hamstring Assessment Tool (PHAT). This is a prospective series of 74 consecutive proximal hamstring surgical repairs in 72 patients, with a median age of 50.5years (range 16-74). Patients completed the PHAT, SF12 Health Survey and Lower Extremity Functional Scale (LEFS). The scoring system was validated by calculating its internal consistency, reproducibility, reliability and sensitivity to change. Construct validity was evaluated using Pearson's correlation analysis to examine the strength of association between the PHAT, LEFS and SF-12 scores. The PHAT showed high completion rate (100%), high internal consistency (Cronbach's alpha 0.80), high reproducibility (ICC 0.84) and high sensitivity to change. There was moderate correlation with the LEFS and low correlation with the Physical Component Score of the SF-12. This study has validated the PHAT as an assessment tool for proximal hamstring tendon injuries. The new questionnaire provides a measure of outcome that is reliable and sensitive to clinically important change. This simple questionnaire provides the clinician with a quick and practical tool for assessing patients with proximal hamstring injuries: to assess pre-operative disability and monitor recovery post-operatively. II.