Review Question - QID 5641

Figures A and B show an acute proximal hamstring tendon avulsion. The next best step in management would be open surgical repair of all tendons to their origin at the ischial tuberosity.

Athletes participating in sports that require sprinting, jumping, acceleration and deceleration are at increased risk of sustaining a proximal hamstring tendon avulsion. The greatest predictor of this injury is prior hamstring injury. Other risk factors include increasing age, high training demand, increased body mass index and tight hip flexor muscles. MRI is the gold standard imaging to identify these images. Open hamstring tendon repair is recommended in athletes when all of the hamstring tendons have avulsed off their origin or 2 tendons have avulsed and retracted more than 2 cm.

Cohen et al. wrote a JAAOS article on acute proximal hamstring rupture. They point out that testing the peroneal branch of the sciatic nerve function is important in the physical examination, as injury to this branch will cause weakness of the short head of the biceps femoris and may slow potential postoperative rehabilitation.

Lefevre et al. reviewed the return to sports after surgical repair of acute proximal hamstring ruptures. They performed a prospective observational study that included 34 patients. Patients returned to sports within a mean 5.7 ± 1.6 months, at the same level in 27 patients (79.4 %) and at a lower level in 7 patients (20.6 %). They conclude that surgical repair of acute proximal hamstring ruptures has the potential to significantly improve the functional prognosis of patients with these injuries.

Figures A and B shows a significant amount of swelling and hematoma around the hamstring tendon. The whole ischial tuberosity is denuded of tendon, which is consistent with a complete rupture. Illustration A shows a large posterior thigh ecchymosis commonly seen with this injury. The ecchymosis presents approximately 1 week following injury, which is know as latent ecchymosis. Illustration B shows a schematic and intraoperative image of the open tendon repair of an acute injury.

Incorrect Answers:
Answers 1 and 5: Nonoperative is recommended in the case of single tendon rupture. Treatment consists of rest, ice, weight bearing as tolerated, NSAIDs, gentle stretching, therapeutic exercise, and gradual return to athletic activity, over approximately 4 to 6 weeks. This patient has ruptured his biceps femoris, semimembranosis, and semitendinosis.
Answer 2: There would be no indication for CT scan. MRI are more sensitive and specific for proximal hamstring ruptures.
Answer 3: There is no intra-articular hip pathology. Some case reports have suggested that endoscopic hamstring repair can be used to treat these injuries, however these are low powered studies.