When Should Hamstring Injuries be Repaired?
abstract & commentary
Synopsis: The vast majority of hamstring injuries are partial tears that do well with nonoperative management. However, patients with severe swelling, pain, and ecchymosis should be re-examined for a palpable defect proximally and profound weakness to resisted knee flexion. Ideally, complete ruptures should be repaired early to facilitate mobilization and accelerate rehabilitation.
Source: Cross MJ, et al. Surgical repair of chronic complete hamstring tendon rupture in the adult patient. Am J Sports Med 1998;26(6):785-788.
Hamstring tears are one of the most common injuries faced by the sports medicine physician. The vast majority of hamstring injuries involve partial tears. These respond to a conservative regimen of rest, stretching, ice followed by heat, and ultrasound, although symptoms may persist for several months and reinjury is common. A small percentage of athletes experience a complete tear of the hamstring tendons from the ischial tuberosity. The generalized swelling and discomfort that comes with an acute injury make the diagnosis, at first, quite difficult. However, as pain and swelling subside, a palpable defect is evident proximally.
Cross and colleagues encountered nine patients with complete hamstring ruptures over a 15-year period. Interestingly, five of the nine occurred in water skiing accidents, with the skier suffering an acute flexion of the hip while being pulled from the water with knees extended. Patients were referred an average of 36 months (range, 2-104 months) after injury because of persistent difficulty running, difficulty walking downhill, leg weakness, and intermittent sciatica despite extensive physical therapy. MRI was helpful to define the tear location if there was any doubt as to the diagnosis. Serous fluid collections were frequently noted.
Repair was performed through a midline approach with the patient prone. A careful neurolysis of extensive scar tissue around the sciatic nerve was necessary in all cases. The proximal end of the tendon was reapproximated to the cuff of tissue on the ischium at the location of the tear using #5 nonabsorbable sutures and suture anchors. Patients kept the knee flexed at 90° in a brace for eight weeks before initiating therapy, but they regained full extension by six more weeks in all cases.
At an average follow-up of four years (range, 6-156 months), all patients subjectively were improved and asymptomatic, with return to activities. All repairs were intact clinically. Strength and endurance testing for the repaired hamstrings were about 60% of the noninvolved side. Sciatic nerve symptoms resolved in all cases.
Comment by David R. Diduch, MS, MD
A complete rupture of the proximal attachment of the hamstring tendons is unusual. The vast majority of hamstring injuries are partial tears that do well with nonoperative management. However, patients with severe swelling, pain, and ecchymosis should be re-examined for a palpable defect proximally and profound weakness to resisted knee flexion.
Ideally, complete ruptures should be repaired early to facilitate mobilization and accelerate rehabilitation. Other studies in the literature are mainly case reports or focus on a few cases in the acute setting.1 Surgical repair of an avulsed ischial apophysis in the skeletally immature patient has been shown to do well.2 This study, however, is the first series of chronic, complete hamstring ruptures treated surgically. Although the series is small, Cross et al clearly demonstrate that clinical success is possible with repair even as late as 104 months after injury. Although patients still had measurable hamstring weakness after surgical treatment, they were all improved subjectively with resolution of preoperative symptoms, and all had returned to activities.
References
1. Ishikawa K, et al. Avulsion of the hamstring muscles from the ischial tuberosity. Clin Orthop 1988;232: 153-155.
2. Wootton JR, et al. Avulsion of the ischial apophysis. The case for open reduction and internal fixation. J Bone Joint Surg Br 1990;72:625-627.
44. Complete hamstring avulsion injuries from the ischial
tuberosity:
a. are usually asymptomatic after the acute injury symptoms
subside.
b. may be healed effectively by surgical repair even many months after injury.
c. usually heal without residual weakness of knee flexion.
d. are often associated with avulsion of the sciatic nerve.
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