Proximal and mid-hamstring strain / tendon tear

Author(s): Daniel C. Herman, MD, Justin Weppner DO, and Sara Raiser MD,

Originally published:01/09/2013

Last updated:04/28/2017

1. DISEASE/DISORDER:

Definition

Hamstring injuries are common injuries in the athletic population and prone to re-injury. Acute mid-hamstring strains and tears of the myotendinous junction are often seen in explosive sporting events. Overuse injury causing proximal hamstring tendinopathy is seen in athletes, including runners.

Etiology

Mid-hamstring strains and proximal hamstring tears are most commonly seen in athletes who require explosive force, such as with sprinting. These hamstring injuries tend to occur at terminal swing phase, during which the hamstrings are long in length while actively contracting.1 Biceps femoris long head is the most commonly affected hamstring muscle with this mechanism of injury.2 In the general population, hamstring injuries are more commonly ischial tuberosity avulsions as opposed to tears of the muscle belly; these injuries occur primarily in older females and the skeletally immature3 and tend to occur with excessive lengthening involving combined hip flexion and knee extension.4 Chronic proximal hamstring tendinopathy is typically seen in the setting of incomplete healing or altered biomechanics such as inflexibility or weakness.

Epidemiology including risk factors and primary prevention

  • Accounts for 12-16% of all injuries in athletes5
  • Risk factors:
    • Prior hamstring injury – 22-34% reinjury rate.5
    • Muscle fatigue
    • Reduced flexibility
    • Muscle strength imbalance
    • Poor core stability
    • Anterior pelvic tilt
      • Slightly increases tension and length of hamstring tendons from ischial tuberosity to distal attachment6
    • Leg length inequality
    • Overuse
  • Primary prevention:
    • Education for students and coaches
    • Pre-participation flexibility screening
    • Incorporate proper flexibility training and adequate warm up into an athletic program.7,8
    • Primary prevention strategies focus on providing guidance for gradual activity progression, since symptoms often result from a sudden increase in either intensity or duration of training.
  • Secondary prevention:
    • Allow for adequate healing/rest from the initial injury to prevent an immediate recurrence.
    • Fifty-nine percent of repeat hamstring injuries will occur within the first month of return to play (RTP). Isometric strength tends to return to level of the uninjured leg by about 20 days post-injury, while flexibility returns within about 50 days post-injury and dynamic strength persists even after RTP.9
    • Increase hamstring flexibility with a graded stretching program.7
    • Eccentric strengthening exercise program may be initiated for tendinopathy.10,11
    • Gradual activity progression, including strengthening, range of motion, and flexibility.

Patho-anatomy/physiology

  • The hamstrings are comprised of three muscles in the posterior thigh:
    • Semitendinosus – originates on the ischial tuberosity and inserts at the pes anserine
    • Semimembranosus – originates on the ischial tuberosity and inserts at the posterior medial tibia
    • Biceps femoris – Long head originates on the ischial tuberosity and inserts on the head of the fibula; short head originates at the posterolateral femur from the linea aspera.
  • Innervation:
    • Semimembranosus, semitendinosus and long head of the biceps femoris -tibial branch of the sciatic nerve (L5-S2)
    • Short head of the biceps femoris – peroneal branch of the sciatic nerve (L5-S2)11
  • The hamstrings have a higher proportion of type II muscle fibers compared with other muscles of the lower extremities. This suggests the muscle can generate high intrinsic tension forces.12
  • Hamstring function during running11
    • At end of forward swing phase: Decelerates knee extension
    • At foot strike: Eccentric hip extension
    • At take-off: Hip extension and knee flexion
  • Acute hamstring tears or high-grade strains may involve the sciatic nerve due to fibrosis and scarring.
  • Chronic tendinopathy is characterized by fibrosis with proximal attachment hyaline degeneration in some cases.13

Disease progression including natural history, disease phases or stages, disease trajectory (clinical features and presentation over time)

  • Muscle Tear Classification:
    • Grade I (mild):
      • No appreciable tissue disruption. Minimal or no loss of function or strength.
    • Grade II (moderate):
      • Tissue damage that reduces strength and function of musculotendinous unit.
    • Grade III (severe):
      • Complete loss of musculotendinous unit, with rupture of muscle and complete loss of function.

Specific secondary or associated conditions and complications

Progression of a chronic tendinopathy to a tendon rupture is rare but can occur.

Associated conditions can include a gait abnormality, leading to dysfunction along the kinetic chain affecting the low back, sacroiliac joint, hip, knee, and ankle joints.

Sciatic nerve can become entrapped due to fibrosis and scarring, particularly in acute tears. This can cause radiating symptoms down the leg with associated pain, weakness and numbness.

2. Essentials of Assessment

History

  • Acute: Sudden onset of pain or pulling sensation in the posterior gluteal region or thigh (with or without a popping sound or sensation) during strenuous activity. High-grade strain or tear may be associated with ecchymosis. There is typically discomfort with activity such as running and kicking as well as with bending at the hips. Pain is often worse with sitting.
  • Subacute/Chronic: Gradual onset of deep buttock pain, which may be vaguely localized. Can be associated with posterior thigh pain. Often worse with sitting.

Physical examination

  • Assess lumbar spine, hips, and bilateral lower extremities.
  • Inspection: Ecchymosis at site of injury. Assess pelvic tilt/obliquity.
  • Palpation: Tenderness to palpation, palpable defect. Examine muscle belly with knee flexed to 90 degrees.
  • Range of motion: Positive bent knee stretch test. Positive Puranen-Orava test. Reduced flexibility of hamstrings.
  • Neurovascular assessment: Test knee flexion and hip extension strength in prone position. Seated slump test and straight leg raise may be positive.

Functional assessment

A sports-specific assessment may be helpful, including run gait analysis, cycling position, etc. Running assessments such as a treadmill analysis, with video evaluation of proper running technique assessing the entire kinetic chain to include the pelvis, thigh, leg, and foot, can be helpful. These can assess for and be helpful in correcting functional deficits. Full pain-free range of motion (ROM) should be achieved before beginning a strengthening program.

Imaging

  • AP pelvis X-ray: Assess for bony avulsion or bony changes of ischial tuberosity.
  • Magnetic resonance imaging (MRI) is the most sensitive for the assessment of bony edema, muscular tears/avulsions, and peritendinous edema, as well as concomitant lesions in the area.
  • Musculoskeletal ultrasound: Longitudinal and transverse images with high-resolution imaging allow for the assessment of a tendon tear, muscular edema, or peritendinous edema.

Supplemental assessment tools

  • Differential diagnosis11
    • Lumbar spine discogenic pain or radiculopathy
    • Sacroiliac joint-mediated pain
    • Sacroiliitis associated with spondyloarthropathy
    • Facet-mediated pain
    • Ischial bursitis
    • Apophysitis/bony avulsion – particularly in pediatric population
    • Pelvic stress fracture
    • Pelvic floor pain
    • Piriformis syndrome
    • Obturator internus or gemelli tear
    • Gluteal muscle pain
    • Chronic posterior thigh compartment syndrome
    • Visceral causes, including gastrointestinal and rectal pain

Early predictions of outcomes

Size and extent of hamstring injury can be utilized to some degree to predict RTP. MRI can be used to grade the injury. In a study of professional athletes, RTP occurred at just over two weeks with grade 1 injuries, just over three weeks with grade 2 injuries, and over 10 weeks with grade 3 injuries.14 There is moderate evidence that MRI can predict return to play; lesions closer to the ischial insertion tend to require a longer time to RTP, and patients without hyperintensity on fluid-sensitive sequences tend to have shorter time to RTP.15

Environmental

Equipment used in sports may play a role. For example, cyclists may benefit from adjustments to the bicycle to off-load the hamstring. Runners may benefit from run gait analysis and appropriate shoe and orthotic insert fitting.

Social role and social support system

Hamstring injuries can be extremely frustrating. The length of recovery and rehabilitation varies widely and can be prolonged. This can lead to prolonged absences from athletics. There is often pressure on athletes from coaches, fans and teammates to return to sport prematurely, which can lead to reinjury or a worsening of the original injury.

Professional Issues

Hamstring injuries can also be frustrating to treat from the medical provider’s standpoint as well. Pressures can be present from the injured athlete as well as the coaching staff to return the athlete to play quickly. Unfortunately, there is often risk of reinjury or worsening of the original injury without adequate rehabilitation.

3. REHABILITATION MANAGEMENT AND TREATMENTS

Available or current treatment guidelines

  • Medications:
    • Non-steroidal anti-inflammatory drugs (NSAIDs) – indicated in the acute setting but not for chronic tendinopathy
  • Physical therapy11,16
    • Soft tissue mobilizations to break up adhesions/scar tissue
    • Progressive stretching and muscle energy techniques to improve flexibility
    • Address pelvic tilt, core strength, and neuromuscular control
      • Neuromuscular inhibition may impair rehabilitation and lead to subsequent maladaptation of hamstring17
    • Neural glides, if indicated
    • Progressive (mainly eccentric, particularly swing-phase specific18) hamstring strengthening exercise program
      • Single/double leg bridge
      • Single/double leg ball curls
      • Single/double leg squats
      • Eccentric single leg squats
      • Eccentric single leg windmill squats – incorporating transverse plane movements
      • Core strengthening exercises
      • Nordic hamstring strengthening – shown to decrease incidence and severity of hamstring injuries in rugby players.19 This exercise preferentially recruits semitendinosis.20
      • Hip extension exercise tends to activate lateral hamstrings more while knee-flexion exercise tends to recruit more medial hamstrings.20
      • One study found that athletes whose rehabilitation program including more agility and trunk stabilization had faster RTP and lower reinjury rates (7.7% compared to 70%) when compared to a program focused more on strengthening and flexibility.21
  • Injections:
    • Controversial and generally unproven
  • Other:
    • May consider orthotics
  • Surgery
    • Usually indicated for avulsion fractures and complete ruptures with greater than 2 cm retraction22
    • May consider for recalcitrant pain after failure of conservative treatments23

At different disease stages

New onset/acute

  • Control of inflammation/pain
    • Relative rest
    • Ice
    • NSAIDs
    • Physical therapy
      • Focusing on soft tissue treatments, flexibility, neural glides

Subacute

    • Progression of physical therapy regimen to include strengthening, which begins with open chain exercises with a progression to more advanced closed chain exercises, followed by a progressive eccentric strengthening program.
      • Specific focus on eccentric component.
    • Secondary prevention with flexibility and adequate warm-up and gradual return to sport.

Chronic

  • No benefit of NSAIDs at this stage
  • Progression of physical therapy regimen to include strengthening, which begins with open chain exercises with a progression to more advanced closed chain exercises, followed by a progressive eccentric strengthening program.
    • Specific focus on eccentric component.
  • Secondary prevention with flexibility and adequate warm-up and gradual return to sport.
  • Surgical management for recalcitrant pain can be considered.

Coordination of care

A multi-disciplinary team approach of treatment professionals is helpful to optimize outcomes. In addition to the physiatrist, physical therapists provide a key role for the recovery of these injuries. Other providers involved may include an orthotist, sports psychologist, and orthopedic surgeon.

Patient & family education

It is important to have communication between the patient/athlete as well as the coach and parents in order to maximize rehabilitation and activity modification to enhance return to sport.

Emerging/unique Interventions

  • A gradual return to activity depends on multiple factors, including the severity of the injury along with the chronicity of the injury.
    • Maintain aerobic fitness early in treatment with swimming and/or upper body ergometer.
    • Incorporate lower body aerobic activities such as pool running, cycling or elliptical machine when normal pain-free range of motion has been restored.
    • Progress gradually with return of sport/running program.
  • Most athletes make a full recovery, although caution remains due to the risk of recurrence.

Translation into practice: practice “pearls”/performance improvement in practice (PIPs)/changes in clinical practice behaviors and skills

  • Acute hamstring injuries are usually self-limiting and generally respond to proper rest and a progressive rehabilitation protocol with good success and return to sport.
  • Chronic hamstring injuries / tendinopathies require a careful examination to assess for other differential diagnoses and usually a more prolonged rehabilitation protocol.
  • As with most tendon injuries, surgery should be reserved for only those who have truly failed a comprehensive and complete conservative management program, including a progressive eccentric exercise program. The exceptions to this may include an avulsion fracture or complete rupture of tendon with greater than 2 cm of retraction, as described above.22 

4. CUTTING EDGE/EMERGING AND UNIQUE CONCEPTS AND PRACTICE

Cutting edge concepts and practice

Sciatic nerve hydrodissection may be an alternative method of decompressing the sciatic nerve in cases of scarring.

5. GAPS IN THE EVIDENCE-BASED KNOWLEDGE

Gaps in the evidence-based knowledge

  • Possible other treatments which are controversial or unproven include the following:
  • Injections:
    • Corticosteroid for an acute tendinitis – peritendinous – avoid injecting into the tendon with needle guidance.24
    • Needle tenotomy in chronic recalcitrant cases25
    • Platelet-rich plasma (PRP), dextrose, autologous blood – function as irritants or proinflammatory agents to induce a healing response
    • Sclerosing polidocanol of the neo-vessels26
    • Aprotinin27
  • Other:
    • Topical nitroglycerin 28
    • Iontophoresis
    • Phonophoresis
    • Therapeutic ultrasound
    • Low-level laser therapy
    • Extracorporeal shock wave therapy
    • Kinesiotape
  • Controversies are typically those surrounding injection therapy:
    • Safety profile of corticosteroid injections in weight-bearing tendons is cause for concern, although data suggests that it is beneficial.29
    • Few studies have evaluated PRP therapies specifically for hamstring tendon injuries; studies that do exist have shown mixed results30.
  • Numerous studies are investigating newer tendinopathy treatments, but most are not looking at the treatment of tendinopathy with regard specifically to the hamstring.

REFERENCES

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Original Version of the Topic

John E. Tobey, MD. Proximal and mid-hamstring strain/tendon tear. 01/09/2013.

Author Disclosures

Daniel C. Herman, MD
NIH, Foudation for PM&R, Foundation for AMSSM, Foundation for ACSM: Research Grants.

Justin Weppner, DO
Nothing to Disclose

Sara Raiser, MD
Nothing to Disclose

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