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Acute Proximal Hamstring Injuries Aaron J. Krych, MD Mayo Clinic Sports Medicine Associate Professor Director, Sports Medicine Fellowship Director, Sports Medicine Research Fellowship

krych.aaron@mayo.edu

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Diagnosis and Management of Acute Proximal Hamstring Tendon Injuries

• History and Exam - Aaron J. Krych, MD • Imaging - Mark S. Collins, MD • Surgical Repair - Indications and

Outcomes - Aaron J. Krych, MD • Non-operative & Post-operative Rehab -

Jeffrey D. Strauss, PT, DPT

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Disclosures • Consultant

• Arthrex, Vericel • Research Support

• Arthritis Foundation, Histogenics, Ceterix, Aesculap, Samumed

• Medical Board of Trustees • MTF

• Editorial Board • AJSM Social Media, MN Orthopedic Society

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History and Exam

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Anatomy • The hamstring is made up of 3

muscles: • Semitendinosus • Semimembranosus • Biceps femoris (long and

short head)

• All 3 innervated by sciatic nerve

• Semi-T and biceps make up conjoint tendon

• Semi-M more lateral long tendon

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Gluteus maximus

Hamstring muscles

Proximal

Distal

Medial Lateral

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Proximal

Distal

Medial Lateral

ST ligament

Adductor magnus tendon

Adductor magnus muscle

Conjoint tendon (Biceps femoris/semi-T)

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Proximal

Distal

Medial Lateral

ST ligament

Conjoint tendon (reflected from bone but partially in continuity with ST ligament)

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Proximal

Distal

Medial Lateral

Ischial tuberosity

Conjoint tendon (reflected)

Semimembranosous

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Function • Knee flexion • Hip extension • 70% fast twitch fibers (quad

50%) • Sprinting • Walking

• Late recovery phase • Provide eccentric control

and knee stability

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Acute Hamstring Tears: Etiology and Mechanism • 12% of hamstring injures involve a tear or

avulsion of the proximal hamstring origin, 9% of which are complete avulsions

• Injury involves a traumatic event with forced hip flexion and combined knee extension

Barnett KSSTA 2014

Dierckman Arthroscopy 2012

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Need to distinguish between hamstring “pull/strain” and avulsion

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History of Mechanism • Avulsions

• Athletes • Waterski, bull-riders,

“splits” • Non-athletes

• Slip on ice • Slip on wet floor

• Hamstring strains • Sprinting—eccentric force

on a lengthened muscle

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Commonly Presenting Symptom • Difficulty Sitting • Buttock Pain • Difficulty walking fast • Weakness • Sciatic nerve symptoms

• Pins and needles in sciatic distribution

• Rare foot drop

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Clinical examination • Dichotomy of presentations

• Doorway sign • Tenderness to palpation

• Localizes well • Strength deficits • Palpable defect • Bruising • Popeye sign

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Gold standard for diagnosis • MRI