February 2025

Hamstring Injuries

By: Justin W. Arner, M.D.,
Member, AANA Communications and Technology Committee

 

Hamstring injuries are complex injuries with high risk of reinjury and missed time from sports and activities of daily living. Mechanism is typically an injury with extended knee and flexed hip. Bruising is a common finding as well as pain. Initial x-rays are important to ensure no bony avulsions are present. MRI is typically recommended to help to determine the location and extent of injury as these factors dictate treatment.

 

Retracted proximal tendon avulsions are commonly treated surgically if they are complete tears from an acute injury in active patients. Open techniques with suture anchors have shown excellent outcomes, high satisfaction and return to activities when performed within one month of injury.1,2,4-6,17,18 Care must be taken in regards to the sciatic nerve during surgical hamstring repair as injury could be catastrophic. In chronic injuries, reconstruction with allograft sometime is required due to scarring and shortening of the tendon. This has been shown to lead to inferior outcomes compared to acute primary repair.2,4,7 Worker’s compensation has been linked to inferior surgical outcomes.13 Peri-incisional numbness and wound issues are the most common complications. In complete retracted tears treated nonoperatively, hamstring scarring to the sciatic nerve, known as hamstring syndrome, can lead to difficult to describe numbness in the nerve distribution which can be quite debilitating.2,4,7 However, predicting who will have this issue is difficult. Partial proximal hamstring injuries are commonly treated without surgery, especially with less than 2 cm of retraction and single tendon tearing. In two tendon tears with retraction >2 cm, surgery commonly is discussed.3,4,18,20,23 Arthroscopic repair for proximal hamstring tears has been discussed with limited outcome data reported to date.12

 

Myotendinous hamstring injuries are usually treated nonoperatively with the typical soft tissue injury grading system utilized with grade one, two and three indicating worsening tearing. Higher grade injuries lead to longer delays in return to sport and activities.9 Reinjury is common with the main risk factors being history of previous injury, increased workload and dehydration.15 Early platelet-rich plasma (PRP) injections have promise to decrease reinjury with the hopes of healing with more normal tissue rather than scar; however, studies are limited.8 Physical examination findings regarding dissipation of pain with resisted hip extension, with the knee in extension, knee flexion while prone at 90, 45, and 20 degrees and reverse plank testing help guide progression to return to play. Return to activities and sport is based on a graduated physical therapy program to regain muscle length without reinjury.4,19 Efforts to prevent reinjury are essential with Nordic hamstring curls showing benefits, but implementation is variable.16,22,24  

 

Recently, distal myotendinous junction injuries have gained interest as a unique pathology that may lead to longer delays in return to sport, termed “T zone” injuries. Literature remains limited on this topic.10,11,14 Distal avulsions must be carefully evaluated as knee injuries can occur in conjunction. Some favor excision or tendon stripping in semimembranosus injuries while distal biceps femoris injuries are typically treated with surgery.21

 

Hamstring injuries are common and differences in treatment and return to activities exist based on location and severity of injury with MRI being helpful to determine this.

 

References

  1. Ahmad, C.S., Redler, L.H., Ciccotti, M.G., et al. Evaluation and Management of Hamstring Injuries. The American Journal of Sports Medicine. 2013;41(12):2933-2947.
  2. Allahabadi, S., Salazar, L.M., Obioha, O.A., et al. Hamstring Injuries: A Current Concepts Review: Evaluation, Nonoperative Treatment, and Surgical Decision Making. The American Journal of Sports Medicine. 2024;52(3):832-844.
  3. Arner, J.W., Freiman, H., Mauro, C.S., Bradley, J.P. Functional Results and Outcomes After Repair of Partial Proximal Hamstring Avulsions at Midterm Follow-up. The American Journal of Sports Medicine. 2019;47(14):3436-3443.
  4. Arner, J.W., McClincy, M.P., Bradley, J.P. Hamstring Injuries in Athletes: Evidence-based Treatment. The Journal of the American Academy of Orthopaedic Surgeons. 2019;27(23):868-877.
  5. Blakeney, W.G., Zilko, S.R., Edmonston, S.J., Schupp, N.E., Annear, P.T. A prospective Evaluation of Proximal Hamstring Tendon Avulsions: Improved Functional Outcomes Following Surgical Repair. Knee Surgery, Sports Traumatology, Arthroscopy: Official Journal of the ESSKA. 2017;25(6):1943-1950.
  6. Bodendorfer, B.M., Curley, A.J., Kotler, J.A., et al. Outcomes After Operative and Nonoperative Treatment of Proximal Hamstring Avulsions: A Systematic Review and Meta-analysis. The American Journal of Sports Medicine. 2018;46(11):2798-2808.
  7. Bowman, E.N., Marshall, N.E., Gerhardt, M.B., Banffy, M.B. Predictors of Clinical Outcomes After Proximal Hamstring Repair. Orthopaedic Journal of Sports Medicine. 2019;7(2):2325967118823712.
  8. Bradley, J.P., Lawyer, T.J., Ruef, S., Towers, J.D., Arner, J.W. Platelet-Rich Plasma Shortens Return to Play in National Football League Players With Acute Hamstring Injuries. Orthopaedic Journal of Sports Medicine. 2020;8(4):2325967120911731.
  9. Cohen, S.B., Towers, J.D., Zoga, A., et al. Hamstring Injuries in Professional Football Players: Magnetic Resonance Imaging Correlation With Return to Play. Sports Health. 2011;3(5):423-430.
  10. Entwisle, T., Ling, Y., Splatt, A., Brukner, P., Connell, D. Distal Musculotendinous T Junction Injuries of the Biceps Femoris: An MRI Case Review. Orthopaedic Journal of Sports Medicine. 2017;5(7):2325967117714998.
  11. Entwisle, T., Marović, P., Schneider, M., Carey, B., Connell, D.G. Distal Musculotendinous T Junction Injuries of the Biceps Femoris: Time to Return to Play in Professional Australian Football League Players. Seminars in Musculoskeletal Radiology. 2019;23:S1 - S18.
  12. Fletcher, A.N., Pereira, G.F., Lau, B.C., Mather, R.C.. Endoscopic Proximal Hamstring Repair Is Safe and Efficacious With High Patient Satisfaction at a Minimum of 2-Year Follow-Up. Arthroscopy. 2021;37(11):3275-3285.
  13. Johnson, E.E., Brutico, J.M., Rangavajjula, L., et al. Open Repair of Complete Proximal Hamstring Avulsions in Workers' Compensation Patients. Orthopaedic Journal of Sports Medicine. 2022;10(9):23259671221119774.
  14. Kayani, B., Ayuob, A., Begum, F., Singh, S., Haddad, F.S. Surgical Repair of Distal Musculotendinous T Junction Injuries of the Biceps Femoris. The American Journal of Sports Medicine. 2020;48(10):2456-2464.
  15. Pas, H.I., Reurink, G., Tol, J.L., et al. Efficacy of rehabilitation (Lengthening) Exercises, Platelet-Rich Plasma Injections, and other Conservative Interventions in acute Hamstring Injuries: An Updated Systematic Review and Meta-Analysis. British Journal of Sports Medicine. 2015;49(18):1197-1205.
  16. Petersen, J., Thorborg, K., Nielsen, M.B., Budtz-Jorgensen, E., Holmich, P. Preventive Effect of Eccentric Training on Acute Hamstring Injuries in Men's Soccer: A Cluster-Randomized Controlled Trial. The American Journal of Sports Medicine. 2011;39(11):2296-2303.
  17. Piposar, J.R., Vinod, A.V., Olsen, J.R., Lacerte, E., Miller, S.L. High-Grade Partial and Retracted (<2 cm) Proximal Hamstring Ruptures: Nonsurgical Treatment Revisited. Orthopaedic Journal of Sports Medicine. 2017;5(2):2325967117692507.
  18. Shambaugh, B.C., Olsen, J.R., Lacerte, E., Kellum, E., Miller, S.L. A Comparison of Nonoperative and Operative Treatment of Complete Proximal Hamstring Ruptures. Orthopaedic Journal of Sports Medicine. 2017;5(11):2325967117738551.
  19. Sheth, U., Dwyer, T., Smith, I., et al. Does Platelet-Rich Plasma Lead to Earlier Return to Sport When Compared With Conservative Treatment in Acute Muscle Injuries? A Systematic Review and Meta-analysis. Arthroscopy. 2018;34(1):281-288.e281.
  20. Subbu, R., Benjamin-Laing, H., Haddad, F. Timing of Surgery for complete Proximal Hamstring Avulsion Injuries: Successful Clinical Outcomes at 6 Weeks, 6 Months, and After 6 Months of Injury. The American Journal of Sports Medicine. 2015;43(2):385-391.
  21. Thompson, J.W., Plastow, R., Kayani, B., et al. Surgical Repair of Distal Biceps Femoris Avulsion Injuries in Professional Athletes. Orthopaedic Journal of Sports Medicine. 2021;9(3):2325967121999643.
  22. van der Horst, N., Smits, D.W., Petersen, J., Goedhart, E.A., Backx, F.J. The Preventive Effect of the nordic Hamstring Exercise on Hamstring Injuries in amateur Soccer Players: A Randomized Controlled Trial. The American Journal of Sports Medicine. 2015;43(6):1316-1323.
  23. van der Made, A.D., Reurink, G., Gouttebarge, V., Tol, J.L., Kerkhoffs, G.M. Outcome After Surgical Repair of Proximal Hamstring Avulsions: A Systematic Review. The American Journal of Sports Medicine. 2015;43(11):2841-2851.
  24. van Dyk, N., Behan, F.P., Whiteley, R. Including the Nordic Hamstring Exercise in Injury Prevention Programmes Halves the Rate of Hamstring Injuries: A Systematic Review and Meta-Analysis of 8459 Athletes. British Journal of Sports Medicine. 2019.
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