Updated: 4/25/2020

Hamstring Injuries

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Introduction
  • Overview
    • hamstring injuries usually occur in running athletes as a result of sudden hip flexion and knee extension
      • treatment is generally conservative but recurrence is very common
  • Epidemiology
    • incidence 
      • make up 30% of new lower extremity injuries in athletes 
        • annual increase of 4% noted in soccer players over last ~15 years
    • demographics
      • most commonly seen in rapid acceleration sports
        • soccer, track and field, and football
    • location
      • myotendinous junction    
        • is the most common site of rupture in adults
        • often occurs during sprinting 
      • avulsion of ischial tuberosity
        • less common
        • seen in skeletally immature
          • 10% of all pelvis avulsion fractures in the skeletally immature
        • seen in water skiers
    • risk factors
      • previous hamstring injury (increases risk of reinjury by factor of 6)
        • previous injury leads to formation of weakened scar tissue lowering threshold to recurrent injury
      • inadequate warm-up
      • strength imbalance (hamstring to quadriceps ratio < 0.6)
      • hamstring strength difference with contralateral leg (> 10-15%)
      • reduced hip extension
      • leg-length differences (shorter leg has tighter hamstrings)
  • Pathophysiology
    • mechanism of injury
      • intramuscular and musculotendinous injuries
        • most often occur during sudden takeoff phase of running
      • proximal hamstring avulsions
        • occurs as a result of hip flexion and knee extension 
          • eccentric contraction of hamstring at the end of swing phase when muscle fibers are at maximal elongation. 
    • pathobiology
      • satellite cell plays a role in muscle healing following muscle injury 
  • Prognosis
    • can be very unpredictable injuries with variable return to sport
    • overall 84% of patients recover pre-injury strength and 89% recover pre-injury endurance
    • worse outcomes seen in severely retracted tears or those with scarring to sciatic nerve
Anatomy
  • Hamstrings 
    • 4 muscles
      • semimembranosus topic
      • semitendinosus topic
      • biceps femoris
        • long head topic
        • short head topic
    • origin
      • all originate on ischial tuberosity except short head 
        • short head originates from linea aspera on femur
        • semimembranosus has most lateral attachment 
    • insertion
      • semimembranosus inserts on posterior aspect of medial tibial condyle
      • semitendinosus inserts on superomedial tibial shaft within the pes anserine
      • biceps femoris long head inserts on fibular head
      • biceps femoris short head has many insertions (fibular head, biceps femoris long head, lateral knee capsule)
    • innervation
      • tibial branch of sciatic nerve: semimembranosus, semitendinosus, long head of biceps femoris
      • common peroneal branch of sciatic nerve: short head of biceps femoris
    • blood supply
      • inferior gluteal artery and profunda femoral artery
    • other
      • hamstring origin on ischial tuberosity is ~6 cm proximal to inferior border of overlying gluteus maximus
      • sciatic nerve is 1.2 cm from lateral bony aspect of hamstring origin
  • Biomechanics 
    • cross and act upon 2 joints: the hip and knee
      • except short head which only crosses the knee joint
Classification  

 

  Hamstring tear MRI classification
Grade 1  •T2 hyperintense signal about a tendon or muscle without fiber disruption
Grade 2  •T2 hyperintense signal around and within a tendon/muscle with fiber disruption less than half the tendon/muscle width
Grade 3  •Tendon/muscle fiber disruption greater than half its tendon/muscle width

 

Presentation
  • History
    • sudden pain in the posterior thigh during running, kicking or jumping activity
    • occasionally a "pop" felt
  • Symptoms
    • common symptoms
      • posterior thigh pain
      • hamstring tightness
      • pain with sitting
        • proximal avulsions
  • Physical exam
    • inspection                                       
      • ecchymosis in posterior thigh 
        • most common seen in proximal avulsions or high grade myotendinous tears
    • palpation
      • may have palpable mass in middle 1/3 of posterior thigh (myotendinous rupture)
      • tenderness to palpation
        • ischial tuberosity
        • myotendinous junction
        • distal tendinous insertions
    • gait
      • "stiff-legged" gait (avoiding knee and hip flexion)
    • motion
      • decreased popliteal angle 
        • flexing hip to 90 degrees with knee flexed to 90 degrees, and then slowly extending knee
          • knee angle where posterior thigh pain is felt is compared to uninjured leg
    • motor
      • weak hamstring strength
        • while prone, knee flexion strength measured with knee at 90 degrees flexion
          • compared to contralateral side
    • neurovascular
      • may have peroneal nerve weakness (foot drop etc.)
    • provocative tests
      • the following tests are positive for hamstring tendinopathy or strain if the patient feels pain
        • Puranen-Orava Test 
          • heel is placed on an elevated surface and patient reaches for toes 
          • sensitivity 0.76, specificity 0.82
        • bent-knee stretch test 
          • with patient supine, hip and knee are maximally flexed and knee is slowly passively extended
          • sensitivity 0.84, specificity 0.87
        • modified bent-knee stretch test
          • with patient supine, hip and knee are maximally flexed and then the knee is rapidly fully extended
          • sensitivity 0.89, specificity 0.91
Imaging
  • Radiographs
    • recommended views
      • AP pelvis, AP and lateral femur
    • findings
      • may show bony avulsion off of ischial tuberosity 
  • MRI
    • indications
      • evaluation of the insertion site and quantify number of involved tendons and degree of tendon retraction
      • evaluate the sciatic nerve location (in chronic cases)
    • findings
      • may show avulsion off ischial tuberosity 
      • tendinopathy will be seen as increased signal intensity in T1-weighted images 
      • partial tears will have increased signal intensity on T2-weighted images 
Treatment
  • Nonoperative
    • rest, ice, NSAIDS, protected weightbearing for 4 weeks followed by stretching and strengthening
      • indications
        • most hamstring injuries
        • all single tendon tears
        • 2 tendon tears with < 2 cm retraction
        • rupture at myotendinous junction
        • less active patients and those with significant medical comorbidities
      • outcomes
        • take up to 6 weeks to heal 
        • only return when strength is 90% of contralateral side to avoid further injury
    • PRP injection
      • indications
        • acute hamstring strains in high level athletes
      • outcomes
        • some low level studies have shown earlier return to play by 3-5 days in NFL players
  • Operative
    • tendon repair 
      • indications
        • proximal avulsion ruptures 
        • partial avulsion that has failed nonoperative management for 6 months (persistent symptoms) 
        • 2 tendons with at least > 2 cm retraction in young, active patients
        • 3 tendon tears
      • outcomes
        • 80% return to preinjury level/sports at 6 months
        • high level of complications with surgery, up to 23% in some studies
          • higher complication rate with repair of chronic cases compared to acute (< 6 weeks)
    • ORIF 
      • indications
        • bony avulsions with > 2 cm displacement 
        • chronic symptomatic bony avulsions
      • outcomes
        • union rates vary across studies 
Techniques
  • rest, ice, NSAIDS, protected weightbearing for 4 weeks followed by stretching and strengthening
    • modalities that have shown benefit
      • massage, ultrasound, electrical stimulation
    • protected weightbearing 
      • most studies state 4 weeks, but should be extended if patient still significantly symptomatic
    • stretching and strengthening
      • as symptoms resolve, abdominal, hip and quadriceps should be added to hamstring strengthening program to prevent reinjury
      • hamstrings should be strengthened to correct any hamstring-quadriceps strength imbalance
    • injury prevention
      • Nordic hamstring exercise 
        • athlete kneels while heels are held on ground by an assistant; the athlete than leans forward until he is prone and then returns to original upright position 
        • shown to reduce injuries by 50-70% in some studies
      • isolated targeting of specific hamstring muscles
        • long head of the biceps femoris and semimembranosus are more active during hip extension 
        • semitendinosus and short head of biceps femoris more active during knee flexion
  • PRP injection
    • recommendation is to administer within 24-48 hours of acute injury
    • ultrasound-guided injection recommended
  • tendon repair
    • positioning
      • prone with leg free so knee can be flexed to relieve hamstring tension. 
    • approach
      • transverse incision over gluteal crease   
        • can be extended distally in "T" configuration for large retracted tear
      • hamstring fascia typically intact
        • vertical fascial incision will often lead to encountering a hematoma or fluid collection
      • sciatic nerve runs on average 1.2 cm lateral to the most lateral aspect of ischial tuberosity
    • technique
      • ischium insertion site should be scraped with a periosteal elevator or curette to improve healing environment
        • avoid burr to decreased risk to sciatic nerve
      • repair to the ischial tuberosity with the use of multiple suture anchors (4-6 suture anchors) with the knee flexed
        • allograft bridge may be needed in severely chronic cases when hamstrings are not able to be re-approximated to tuberosity
          • Achilles allograft has shown comparable results to acute repairs in small studies. d
    • post-operative protocol
      • patients typically made partial weight bearing for 4-6 weeks with knee flexed to 40 degrees 
        • knee brace or hip brace can be used
  • ORIF
    • approach 
      • as above
    • technique
      • direct reduction followed by fixation with multiple partially or fully threaded screws with washers 
        • can supplement with suture anchors and/or interference screws  
Complications
  • Recurrence (most common complication)
    • incidence
      • 12-31% of patients sustain repeat injury
    • risk factors 
      • hamstring weakness
      • hamstring-quad imbalance
      • premature return to activity 
  • Peroneal nerve injury
    • risk factors
      • distal non-insertional hamstring injuries 
    • treatment
      • usually self-resolving 
  • Sciatic nerve injury
    • incidence 
      • 8% of surgical cases
    • risk factors
      • chronic cases with scarring of the nerve to the hamstring
    • treatment
      • nerve exploration
  • Hamstring syndrome
    • localized posterior buttock and ischial tuberosity pain secondary to nonoperatively treated hamstring avulsion injuries
    • treatment
      • surgical release and sciatic nerve decompression
  • ischial tuberosity nonunion
    • risk factors
      • bony avulsion fractures > 2 cm treated nonoperatively
    • treatment
      • ORIF +/- bone graft
 
 

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(OBQ12.152) Which of the following most accurately describes the primary role of satellite cells? Review Topic | Tested Concept

QID: 4512
1

To act as an intermediary in the cell-signalling pathway for bone remodeling

23%

(1183/5113)

2

To regenerate skeletal muscle after muscle injury

67%

(3427/5113)

3

To regenerate periosteum after periosteal damage in a child

3%

(163/5113)

4

To bind chemotherapeutic ligands in the treatment of lymphoma of bone

2%

(103/5113)

5

To express high amounts of sonic hedgehog surface protein

4%

(187/5113)

L 4 C

Select Answer to see Preferred Response

(OBQ07.217) Concomitant flexion of the hip and extension of the knee is most likely to result in an injury to which structure? Review Topic | Tested Concept

QID: 878
1

Sartorius

7%

(216/3314)

2

Rectus femoris

10%

(346/3314)

3

Adductor magnus

0%

(16/3314)

4

Biceps Femoris

81%

(2686/3314)

5

Tensor fascia lata

1%

(45/3314)

L 2 C

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(OBQ07.175) A 15-year-old boy sustains the injury seen in Figure A while running the hurdles. The same mechanism in an adult athlete would most likely result in which of the following injuries? Review Topic | Tested Concept

QID: 836
FIGURES:
1

Hamstring myotendinous junction rupture

66%

(1090/1661)

2

Pelvic ramus fracture

2%

(25/1661)

3

Hamstring muscle belly rupture

3%

(56/1661)

4

Hamstring tendinous insertion rupture

28%

(468/1661)

5

Sports hernia

1%

(21/1661)

L 3 C

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