Review Question - QID 219892

Figure B is an MRI of a complete proximal hamstring avulsion injury with retraction in a high-performance athlete - this injury should be treated with surgical repair (Answer 2).

Proximal hamstring injuries often result from a rapid, explosive movement combining hip flexion and knee extension, which places maximum tension on the muscle-tendon unit. Acute injuries typically involve the biceps femoris. Less commonly, chronic hamstring injuries result from repetitive stretching of the muscle with combined hip flexion and knee extension, most often affecting the proximal end of the semimembranosus. While partial tears may be initially managed nonoperatively, conservative treatment of complete tears has frequently resulted in poorer outcomes, therefore operative repair is indicated in cases of complete tears, leading to improved functional outcomes and strength.

Degen published a 2019 review on proximal hamstring injuries. The author stated that proximal hamstring tendinopathy and partial-thickness tears can often successfully be managed with a combination of non-operative modalities, including physiotherapy focused on eccentric strengthening, shock wave therapy, or peri-tendinous injections. For complete ruptures, conservative treatment usually results in unsatisfactory outcomes, with residual weakness, reduced function, and poor return-to-sport rates. Surgical repair can provide satisfactory outcomes, with good to excellent functional outcomes and strength, with acute treatment preferred over delayed, chronic repair.

Chang et al. published a 2020 review on the management of proximal hamstring injuries. The authors emphasized the high variability in conservative management, citing variable times for convalescence and return to a pre-injury level of sporting function. Operative treatment is indicated in patients with acute avulsion injuries with or without tendon retraction, high-grade proximal or distal musculotendinous injuries, and chronic injuries with persistent pain or functional compromise refractory to nonoperative treatment. Operative treatment is associated with high patient satisfaction, restoration of strength, improved functional outcomes, and a high return to pre-injury level of activity.

Figure A is an MRI demonstrating increased signal at the anterior talofibular ligament (ATFL) suggesting a low ankle sprain.
Figure B is an MRI demonstrating a complete proximal hamstring avulsion injury with retraction over 5cm.
Figure C is a radiograph demonstrating a PCL avulsion fracture.
Figure D is an MRI demonstrating a partial-thickness rotator cuff tear.
Figure E is an MRI demonstrating a compression-sided femoral neck stress fracture less than 50% of the neck width.

Incorrect Answers:
Answer 1: First-line treatment for a low ankle sprain, especially in a recreational athlete, is rest, ice, and early functional rehabilitation.
Answer 3: First-line treatment for a PCL avulsion fracture is nonoperative management with a focus on quadriceps strengthening.
Answer 4: First-line treatment for a partial rotator cuff tear is anti-inflammatory medication and physical therapy.
Answer 5: First-line treatment for a compression-sided femoral neck stress fracture is activity restriction and non-weight bearing.