Proximal Hamstring Avulsions, from Diagnosis to Treatment: A Review Regarding a Clinical Case

Abstract

Proximal hamstring avulsion is a rare injury that can produce permanent functional alterations, in addition to a high risk of retear (in up to 30% of the cases). It usually occurs in athletes who perform rapid accelerations or require ballistic movements during their training, although they also occur in a more sedentary population due to low-energy mechanisms. The most frequent mechanism of injury is an eccentric contraction of the proximal hamstrings when trying to resist a fall, with the hip in flexion and the knee in extension.

Numerous clinical signs are described at the physical examination. Regarding its study, although conventional radiography and ultrasound are very useful, magnetic resonance is recognized as the gold standard for its precise diagnosis.

Treatment will depend on the type of patient and their expectations, although in recent years the surgical option has been increasingly considered in cases of complete avulsion of the hamstrings associated with retraction.

We herein present a review of the topic in relation to a clinical case that was resolved surgically, and we discuss the basic concepts, clinical presentation, complementary images, and treatment options that are currently available.

Keywords

avulsion lesions - proximal hamstring - surgical treatment of proximal hamstring avulsions - hamstring rehabilitation

Publication History

Received: 08 June 2022

Accepted: 07 March 2023

Article published online:
18 May 2023

• Referencias

• 1 Ishikawa K, Kai K, Mizuta H. Avulsion of the hamstring muscles from the ischial tuberosity. A report of two cases. Clin Orthop Relat Res 1988; (232) 153-155
• 2 Chakravarthy J, Ramisetty N, Pimpalnerkar A, Mohtadi N. Surgical repair of complete proximal hamstring tendon ruptures in water skiers and bull riders: a report of four cases and review of the literature. Br J Sports Med 2005; 39 (08) 569-572
• 3 Croisier JL. Factors associated with recurrent hamstring injuries. Sports Med 2004; 34 (10) 681-695
• 4 Koulouris G, Connell D. Evaluation of the hamstring muscle complex following acute injury. Skeletal Radiol 2003; 32 (10) 582-589
• 5 Stępień K, Śmigielski R, Mouton C, Ciszek B, Engelhardt M, Seil R. Anatomy of proximal attachment, course, and innervation of hamstring muscles: a pictorial essay. Knee Surg Sports Traumatol Arthrosc 2019; 27 (03) 673-684
• 6 Miller SL, Gill J, Webb GR. The proximal origin of the hamstrings and surrounding anatomy encountered during repair. A cadaveric study. J Bone Joint Surg Am 2007; 89 (01) 44-48 DOI: 10.2106/JBJS.F.00094.
• 7 Irger M, Willinger L, Lacheta L, Pogorzelski J, Imhoff AB, Feucht MJ. Proximal hamstring tendon avulsion injuries occur predominately in middle-aged patients with distinct gender differences: epidemiologic analysis of 263 surgically treated cases. Knee Surg Sports Traumatol Arthrosc 2020; 28 (04) 1221-1229
• 8 van der Made AD, Reurink G, Gouttebarge V, Tol JL, Kerkhoffs GM. Outcome after surgical repair of proximal hamstring Avulsions: a systematic review. Am J Sports Med 2015; 43 (11) 2841-2851
• 9 Clanton TO, Coupe KJ. Hamstring strains in athletes: diagnosis and treatment. J Am Acad Orthop Surg 1998; 6 (04) 237-248
• 10 Bertiche P, Mohtadi N, Chan D, Hölmich P. Proximal hamstring tendon avulsion: state of the art. J ISAKOS 2021; 6 (04) 237-246 DOI: 10.1136/jisakos-2019-000420.
• 11 Degen RM. Proximal hamstring injuries: management of tendinopathy and avulsion injuries. Curr Rev Musculoskelet Med 2019; 12 (02) 138-146
• 12 Wilson TJ, Spinner RJ, Mohan R, Gibbs CM, Krych AJ. Sciatic nerve injury after proximal hamstring avulsion and repair. Orthop J Sports Med 2017; 5 (07) 2325967117713685
• 13 Ali K, Leland JM. Hamstring strains and tears in the athlete. Clin Sports Med 2012; 31 (02) 263-272
• 14 Koulouris G, Connell D. Hamstring muscle complex: an imaging review. Radiographics 2005; 25 (03) 571-586
• 15 Mariani C, Caldera FE, Kim W. Ultrasound versus magnetic resonance imaging in the diagnosis of an acute hamstring tear. PM R 2012; 4 (02) 154-155
• 16 Wood DG, Packham I, Trikha SP, Linklater J. Avulsion of the proximal hamstring origin. J Bone Joint Surg Am 2008; 90 (11) 2365-2374
• 17 Shambaugh BC, Olsen JR, Lacerte E, Kellum E, Miller SL. A comparison of Nonoperative and operative treatment of complete proximal hamstring ruptures. Orthop J Sports Med 2017; 5 (11) 2325967117738551
• 18 Bodendorfer BM, Curley AJ, Kotler JA. et al. Outcomes after operative and Nonoperative treatment of proximal hamstring Avulsions: a systematic review and meta-analysis. Am J Sports Med 2018; 46 (11) 2798-2808
• 19 Cohen SB, Rangavajjula A, Vyas D, Bradley JP. Functional results and outcomes after repair of proximal hamstring avulsions. Am J Sports Med 2012; 40 (09) 2092-2098
• 20 Pihl E, Skoldenberg O, Nasell H, Jonhagen S, Kelly Pettersson P, Hedbeck CJ. Patient-reported outcomes after surgical and non-surgical treatment of proximal hamstring avulsions in middle-aged patients. BMJ Open Sport Exerc Med 2019; 5 (01) e000511 DOI: 10.1136/bmjsem-2019-000511.
• 21 Harris JD, Griesser MJ, Best TM, Ellis TJ. Treatment of proximal hamstring ruptures - a systematic review. Int J Sports Med 2011; 32 (07) 490-495
• 22 Cohen S, Bradley J. Acute proximal hamstring rupture. J Am Acad Orthop Surg 2007; 15 (06) 350-355
• 23 Sallay PI, Ballard G, Hamersly S, Schrader M. Subjective and functional outcomes following surgical repair of complete ruptures of the proximal hamstring complex. Orthopedics 2008; 31 (11) 1092
• 24 Mendiguchia J, Alentorn-Geli E, Brughelli M. Hamstring strain injuries: are we heading in the right direction?. Br J Sports Med 2012; 46 (02) 81-85
• 25 Factor S, Khoury A, Atzmon R, Vidra M, Amar E, Rath E. Combined endoscopic and mini-open repair of chronic complete proximal hamstring tendon avulsion: a novel approach and short-term outcomes. J Hip Preserv Surg 2021; 7 (04) 721-727 DOI: 10.1093/jhps/hnab006.
• 26 Domb BG, Linder D, Sharp KG, Sadik A, Gerhardt MB. Endoscopic repair of proximal hamstring avulsion. Arthrosc Tech 2013; 2 (01) e35-e39
• 27 Laskovski JR, Kahn AJ, Urchek RJ, Guanche CA. Endoscopic proximal hamstring repair and ischial bursectomy using modified portal placement and patient positioning. Arthrosc Tech 2018; 7 (11) e1071-e1078
• 28 Moatshe G, Chahla J, Vap AR. et al. Repair of Proximal Hamstring Tears: A Surgical Technique. Arthrosc Tech 2017; 6 (02) e311-e317
• 29 Ahmad CS, Redler LH, Ciccotti MG, Maffulli N, Longo UG, Bradley J. Evaluation and management of hamstring injuries. Am J Sports Med 2013; 41 (12) 2933-2947 DOI: 10.1177/0363546513487063.
• 30 Ibañez F, Galan H, Milanesio E. et al. Avulsión proximal de tendones isquiotibiales: tratamiento quirúrgico en deportistas de alto rendimiento. Reporte de caso. Rev Asoc Argent Traumatol del Deporte. 2015; 22 (01) 49-56
• 31 Birmingham P, Müller M, Wickiewicz T, Cavanaugh J, Rodeo S, Warren R. Functional outcome after repair of proximal hamstring avulsions. J Bone Joint Surg Am 2011; 93 (19) 1819-1826 DOI: 10.2106/JBJS.J.01372.
• 32 Sallay PI, Friedman RL, Coogan PG, Garrett WE. Hamstring muscle injuries among water skiers. Functional outcome and prevention. Am J Sports Med 1996; 24 (02) 130-136 DOI: 10.1177/036354659602400202.
• 33 Sandmann GH, Hahn D, Amereller M. et al. Mid-term Functional Outcome and Return to Sports after Proximal Hamstring Tendon Repair. Int J Sports Med 2016; 37 (07) 570-576 DOI: 10.1055/s-0035-1564170.
• 34 Lutz PM, Knörr M, Geyer S, Imhoff AB, Feucht MJ. Delayed proximal hamstring tendon repair after ischial tuberosity apophyseal fracture in a professional volleyball athlete: a case report. BMC Musculoskelet Disord 2021; 22 (01) 578 DOI: 10.1186/s12891-021-04468-2.
• 35 Hamming MG, Philippon MJ, Rasmussen MT. et al. Structural properties of the intact proximal hamstring origin and evaluation of varying avulsion repair techniques: an in vitro biomechanical analysis. Am J Sports Med 2015; 43 (03) 721-728