1

Hamstring syndrome -

proximal tendinopathy

Sakari Orava Prof, MD, PhD

Turku, Finland

2

Gluteal and hamstring anatomy

1. m. gluteus maximus2. m. gluteus medius3. m. piriformis4. m. gemell. super.5. m. obtur. int.6. m. gemell. inf.7. m. quadr. fem.8. mm. semitend./ bic. fem9. m. semimembr.tb trochanter bursagb gluteal bursaib ischiogluteal bursa

3

Gluteal and hamstring anatomy

4

Anatomy of hamstring muscle

origin

5

Pain syndromes causing hamstring

area pain

� lumbar disc prolapse or protrusion� disc degeneration – internal tear

� spinal stenosis – nerve root canal stenosis

� spondylolysis, -olisthesis� vertebral apophyseal ring fracture

� vertebral anomalies� other radicular and pseudoradicular pains

� neurological diseases

� neuritis of sciatic nerve� neurinoma of sciatic nerve

6

Piriformis syndrome

� pain at upper gluteal area� radiation to posterior thigh

and down the leg� postexercise and at night

pain� leg held in semiflexion and

in outward rotation in bed� sitting usually OK, long time

difficult� first reported by Yeman

(1928)� first liberation of sciatic

nerve at gluteal area byFreiberg & Winke (1934)

7

Hamstring pains and injuries

1. hamstring syndrome2. hamstring tears (total, partial)

3. avulsion fracture of ischium

4. apophysitis of ischial bone

5. posterior compartment syndrome of thigh

6. neurological syndromes – ”tight

hamstrings”

8

Hamstring syndromeSymptoms Clinical signs

� pain at ischial tuberosityarea

� sitting uncomfortable and painful

� car driving difficult� radiation to posterior thigh,

seldom distally� often recurrent ”hamstring

tears” in history� running with long stride

difficult� exertion pain at ischial

tuberosity and posterorthigh

� palpation pain over ischialtuberosity

� hurdler´s stretch test(Puranen-Orava test) usually+

� side difference in forewardsbending

� straight leg rising often+ (tightness of hamstrings)

� neurological status –� atrophy of posterior thigh in

longstanding cases

9

Pathophysiology of hamstring syndrome= tendinosis (+ sciatic nerve irritation)

� stress, small tears, thickening, tendinosis

� semimembranosustendon mostly affected(=fibrous band)

� biceps femorissometimes, too

10

Diagnosis of hamstring syndrome

� running,sitting and cardriving difficult

� local pain at hamstringinsertion

� MRI +, US +-,ENMG -

11

Radiological diagnosis of hamstring

syndrome (MRI)

12

”Posttraumatic”

hamstring syndrome

� after partial tear or

after recurrent

small tears

fibrosis and

tendinosis occurs

to semimembr.- bic.fem

13

Partial hamstring tears –

posttraumatic hamstring syndrome

� painful scar

� muscle atrophy

� poor healing in active athletes

� different types

� myotendinous tears

14

Histology of hamstring syndrome

� ”fibrous band” is a

tendinotic, thickened

semimembranosus

tendon

� Fibrosis, tendinosis,

chondroid metaplasia

15

Conservative treatment of

hamstring syndrome

� rest from physicalexercise causing pain

� avoid long sitting

� mobility exercises of hip

joint

� muscle strengthing

� local cold, warmth,

physiotherapy

� good warm-up

� massage

� manual treatment

� avoidance of passive and active (over)stretching

� Isometric /eccentrichamstring exercises

� pain and NSAID

medication

� corticosteroid injections

16

Surgical treatment of hamstring

syndrome

� Incisions:

1. Modified Kocher´s

(low ”southern”)

2. Transversal

3. Longitudinal

17

Surgical treatment of hamstring

syndrome

� division of semimembr.band, liberation of sciatic nerve, proximal fasciotomy

18

Surgical treatment of post-

traumatic hamstring syndrome

- division of fibrous tendinosistendon

- excision of scar clump

- fixation of distal stump to other tendons or with sutureanchor to bone

- liberation of nerve

19

Surgery for hamstring syndrome

MATERIAL

� 89 operations to 81 athletes during 7 years

� 5 x both sides at the same time, 3 x at different

times

� 68 operations to men, 21 to women

� Mean age 33 years (men 32, women 36 years)

� Right side 55 %, left 45 %

20

Surgery for hamstring syndrome

MATERIAL� Sports: endurance running 22, soccer 17,

jogging 16, sprinting / hurdling 7, ice hockey 6, weight lifting, gymnastics,orienteering and middle distance running each one athele

� Non-traumatic 62, traumatic 19

� Time from symptoms to surgery 11 months (4 –41 months)

� X-rays 45, MRI 66 pts

21

Surgery for hamstring syndrome

� Tenotomy of semimembr. tendon 89

� Suturation to othertendons 35

� Mitek´s anchor 27

DIAGNOSIS:

� Hamstring syndrome 67

� Posttraum hamstr sdr 22

22

Results

� Excellent 46

� Good 31

� Moderate 10

� Poor 2

� Reoperations 6

23

Postoperative complications of hamstring sdr operations

� postoperative bleeding / hematoma 3

� lesions to posterior cutateous femoral nerve 2

� lesions to muscular branches of sciatic nerve 0

� lesions to perineal nerve branches 1

� postoperative fibrosis 4

� postoperative infection, fistulae 1

� scar problem (keloid, transversal fissuraes) 3

24

Hamstring syndrome in athletes

� hamstring sdr develops usually as overuse sdr

� hamstring injuries/sdr quite common in athletes

and usually heal well – posttraumatic hamstring

sdr may occur

� right diagnosis often difficult

� decision and timing of surgery difficult

� possible to treat surgically with good result

25

Surgical treatment of

hamstring syndrome

in athletes

Lasse Lempainen, Janne Sarimo, Jouni Heikkilä, Sakari Orava