HISTORY A 27 y/o professional hockey player presented with a one year hx of left buttock pain after being slashed by a hockey stick in the middle of the left posterior thigh. He began having low grade aching buttock pain. He could not move for a short period of time and then began to resume progressive activities. After a month he was able to do cycling but with side-to-side maneuvers he had severe buttock and hamstring pain. An MRI of his hip area was unremarkable. Massages only provided transient relief. He is having increased difficulty sitting on hard surfaces. He has a sense of tightness in the buttocks area. Despite the pain he has continued to play but states that it has affected his athletic performance. He has slight degree of lower back pain. He has numbness over the back of the left thigh and lateral aspect of the leg and foot. Some disc bulges have been reported on a previous MRI of the lumbo-sacral area prior to the injury. PHYSICAL EXAMINATION Full ROM of the back. Non-tender over the spinous processes of the lower back. Straight leg raising is negative but he lacks 15 degrees on the left. Has a sense of tightness in the ischial area. With the hip flexed to 90 degrees and progressive internal rotation he has reproduction of his symptoms. There is pain with palpation over the proximal lateral ischium. No clear weakness on examination of the left leg. No wasting or fasciculations noted. Decreased pin-prick over the lateral posterior thigh and the lateral leg and foot. Reflexes present and symmetrical. Normal gait. Increased tone in the left hamstring group. DIFFERENTIAL DIAGNOSIS Disc herniation and L5 radiculopathy/sciatica. Piriformis syndrome. Proximal hamstring syndrome. Hamstring tendonitis. TESTS AND RESULTS NCS of the left leg:-delay in the tibial motor F-wave latency response-unable to obtain sural sensory response-normal peroneal motor response EMG of the left leg, buttock, and lumbo-sacral paraspinal area: -normal -no evidence of acute denervation or advanced chronic denervation/reinnervation anywhere MRI Lumbar: -L3-L5 levels demonstrate mild spondylosis with disc narrowing, desiccation, and diffuse concentric annulus bulge without new progressive focal or lateralizing disc extrusion or limiting stenosis of the central spinal canal or L3,L4 neural foramina -L5-S1 level demonstrates mild spondylosis with disc narrowing, desiccation, and diffuse concentric annulus bulge. There is mild broad based right paracentral and latera/intraforminal disc protrusion with mild impression on the exiting right S1 nerve root and right L5 neural foramen. FINAL/WORKING DIAGNOSIS Proximal hamstring syndrome. TREATMENT AND OUTCOMES Proximal hamstring release, sciatic nerve decompression, and Alloderm tissue wrapped around sciatic nerve to prevent scar tissue from forming. 2 weeks after surgery started gentle progressive ROM, gentle concentric and eccentric hamstring exercises, and water therapeutic exercises. At 6 weeks can straight leg raise beyond 90 degrees without pain over the ischium, no numbness or tingling down the left leg. At 9 weeks unable to sprint, has weakness but no sharp pain, taking cox-2 inhibitor, has returned to skating but no scrimmage yet, sitting tolerance improved. Return to full NHL level play antioriated.