Treatment of Proximal Hamstring Ruptures – A Systematic Review

 

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Abstract

Proximal hamstring ruptures are increasingly treated surgically, despite little high-level supporting evidence. We sought to determine whether there are differences in clinical outcome after surgical vs. non-surgical treatment of proximal hamstring tendinous avulsions/ruptures and acute vs. chronic surgical repair of tendinous avulsions. Multiple medical databases were searched for Level I–IV evidence. 18 studies were included. 298 subjects (300 proximal hamstring injuries) were analyzed with mean age of 39.7 years. 286 injuries were managed with surgical repair vs. 14 non-operative. 95 surgical cases were performed within 4 weeks of the injury (acute), while 191 were performed beyond 4 weeks (chronic). 292 injuries were tendinous avulsions while 8 were bony tuberosity avulsions. Surgical repair resulted in significantly (p<0.05) better subjective outcomes, greater rate of return to pre-injury level of sport, and greater strength/endurance than non-surgical management. Similarly, acute surgical repair had significantly better patient satisfaction, subjective outcomes, pain relief, strength/endurance, and higher rate of return to pre-injury level of sport than chronic repair (p<0.001) with reduced risk of complications and re-rupture (p<0.05). Chronic surgical repair also improves outcomes, strength and endurance, and return-to-sport, but not as well as acute repair. Non-operative treatment results in reduced patient satisfaction, with significantly lower rates of return to pre-injury level of sport and reduced hamstring muscle strength.

References

• 1 Anzel J, Covey K, Weiner A. Disruption of muscles and tendons. An analysis of 1 014 cases.  Surgery. 1959;  45 406-414
  PubMedGoogle Scholar
• 2 Arnason A, Sigurdsson S, Gudmundsson A, Holme I, Engebretsen L, Bahr R. Risk factors for injuries in football.  Am J Sports Med. 2004;  32 5S-16S
  CrossrefPubMedGoogle Scholar
• 3 Blasier R, Morawa L. Complete rupture of the hamstring origin from water skiing injury.  Am J Sports Med. 1990;  18 435-437
  CrossrefPubMedGoogle Scholar
• 4 Brandser E, El-Khoury G, Kathol M, Callaghan J, Tearse D. Hamstring injuries: Radiographic, conventional tomographic, CT, and MR imaging characteristics.  Musculoskeletal Radiol. 1995;  197 257-262
  PubMedGoogle Scholar
• 5 Brucker P, Imhoff A. Functional assessment after acute and chronic complete ruptures of the proximal hamstring tendons.  Knee Surg Sports Traumatol Arthrosc. 2005;  13 411-418
  CrossrefPubMedGoogle Scholar
• 6 Carmichael J, Packham I, Trikha S, Wood D. Avulsion of the proximal hamstring origin. Surgical technique.  J Bone Joint Surg Am. 2009;  91 249-256
  CrossrefPubMedGoogle Scholar
• 7 Chakravarthy J, Ramisetty N, Pimpalnerkar A. 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;  39 569-572
  CrossrefPubMedGoogle Scholar
• 8 Cohen S, Bradley J. Acute proximal hamstring rupture.  J Am Acad Orthop Surg. 2007;  15 350-355
  PubMedGoogle Scholar
• 9 Connell D, Schneider-Kolsky M, Hoving J. Longitudinal study comparing sonographic and MRI assessments of acute and healing hamstring injuries.  Am J Roentgenol. 2004;  183 975-984
  CrossrefPubMedGoogle Scholar
• 10 Cross M, Vandersluis R, Wood D. Surgical repair of chronic complete hamstring tendon rupture in the adult patient.  Am J Sports Med. 1998;  26 785-788
  CrossrefPubMedGoogle Scholar
• 11 DePalma A, Silberstein C. Avulsion fracture of the ischial tuberosity in siblings.  Clin Orthop Relat Res. 1965;  38 120-122
  PubMedGoogle Scholar
• 12 DeSmet A, Best T. MR imaging of the distribution and location of acute hamstring injuries in athletes.  Am J Roentgenol. 2000;  174 393-399
  CrossrefPubMedGoogle Scholar
• 13 Engebretsen A, Myklebust G, Holme I, Engebretsen L, Bahr R. Intrinsic risk factors for hamstring injuries among male soccer players.  Am J Sports Med. 2010;  38 1147-1153
  CrossrefPubMedGoogle Scholar
• 14 Floor S, van der Veen A, Devilee R. Two patients with a complete proximal rupture of the hamstring.  Arch Orthop Trauma Surg. 2010;  130 523-526
  CrossrefPubMedGoogle Scholar
• 15 Folsom G, Larson C. Surgical treatment of acute versus chronic complete proximal hamstring ruptures – results of a new allograft technique for chronic reconstructions.  Am J Sports Med. 2007;  36
  PubMedGoogle Scholar
• 16 Gidwani S, Bircher M. Avulsion injuries of the hamstring origin – a series of 12 patients and management algorithm.  Ann R Coll Surg Engl. 2007;  89 394-399
  CrossrefPubMedGoogle Scholar
• 17 Gidwani S, Jagiello J, Bircher M. Avulsion fracture of the ischial tuberosity in adolescents-an easily missed diagnosis.  Br Med J. 2004;  329 99-100
  CrossrefPubMedGoogle Scholar
• 18 Harris W. Traumatic arthritis of the hip after dislocation and acetabular fractures: treatment by mold arthroplasty. An end-result study using a new method of result evaluation.  J Bone Joint Surg Am. 1969;  51 737-755
  CrossrefPubMedGoogle Scholar
• 19 Ishikawa K, Kai K, Mizuta H. Avulsion of the hamstring muscles from the ischial tuberosity.  Clin Orthop Relat Res. 1988;  232 153-155
  PubMedGoogle Scholar
• 20 Klingele K, Sallay P. Surgical repair of complete proximal hamstring tendon ruptures.  Am J Sports Med. 2002;  30 742-747
  CrossrefPubMedGoogle Scholar
• 21 Konan S, Haddad F. Successful return to high level sports following early surgical repair of complete tears of the proximal hamstring tendons.  Int Orthop. 2010;  34 119-123
  CrossrefPubMedGoogle Scholar
• 22 Koulouris G, Connell D. Evaluation of the hamstring muscle complex following acute injury.  Skeletal Radiol. 2003;  32 582-589
  CrossrefPubMedGoogle Scholar
• 23 Kujala U, Orava S, Karpakka J, Leppavuori J, Mattila K. Ischial tuberosity apophysitis and avulsion among athletes.  Int J Sports Med. 1997;  18 149-155
  Article in Thieme ConnectPubMedGoogle Scholar
• 24 Kurosawa H, Nakasita K, Nakasita H, Sasaki S, Takeda S. Complete avulsion of the hamstring tendons from the ischial tuberosity. A report of two cases sustained in judo.  Br J Sports Med. 1996;  30 72-74
  CrossrefPubMedGoogle Scholar
• 25 Lempainen L, Sarimo J, Orava S. Recurrent and chronic complete ruptures of the proximal origin of the hamstring muscles repaired with fascia lata autograft augmentation.  Arthroscopy. 2007;  23 441.e441-441.e445
  PubMedGoogle Scholar
• 26 Levine W, Bergfeld J, Tessendorf W, Moorman C. Intramuscular corticosteroid injection for hamstring injuries: a 13-year experience in the NFL.  Am J Sports Med. 2000;  28 297-300
  PubMedGoogle Scholar
• 27 Marx R, Fives G, Chu S, Daluiski A, Wolfe S. Allograft reconstruction for symptomatic chronic complete proximal hamstring tendon avulsion.  Knee Surg Sports Traumatol Arthrosc. 2009;  17 19-23
  CrossrefPubMedGoogle Scholar
• 28 McGregor C, Ghosh S, Young D, Maffulli N. Traumatic and overuse injuries of the ischial origin of the hamstrings.  Disabil Rehabil. 2008;  30 1597-1601
  CrossrefPubMedGoogle Scholar
• 29 Mica L, Schwaller A, Stoupis C, Penka I, Vomela J, Vollenweider A. Avulsion of the hamstring muscle group: a follow-up of 6 adult non-athletes with early operative treatment: a brief report.  World J Surg. 2009;  33 1605-1610
  CrossrefPubMedGoogle Scholar
• 30 Murray P, Lowe W. Achilles allograft reconstruction of a chronic complete proximal hamstring rupture.  Knee Surg Sports Traumatol Arthrosc. 2009;  17 1360-1363
  CrossrefPubMedGoogle Scholar
• 31 Obremskey W, Pappas N, Attallah-Wasif E, Tornetta P, Bhandari M. Levels of evidence in orthopaedic journals.  J Bone Joint Surg Am. 2005;  87 2632-2638
  CrossrefPubMedGoogle Scholar
• 32 Orava S, Kujala U. Rupture of the ischial origin of the hamstring muscles.  Am J Sports Med. 1995;  23 702-705
  CrossrefPubMedGoogle Scholar
• 33 Orchard J, Best T. The management of muscle strain injuries: an early return versus the risk of recurrence.  Clin J Sports Med. 2002;  12 3-5
  CrossrefPubMedGoogle Scholar
• 34 Rossi F, Dragoni S. Acute avulsion fracture of the pelvis in adolescent competitive athletes: prevalence, location and sports distribution of 203 cases collected.  Skeletal Radiol. 2001;  30 127-131
  CrossrefPubMedGoogle Scholar
• 35 Sallay P, Ballard G, Hamersly S, Schrader M. Subjective and functional outcomes following surgical repair of complete ruptures of the proximal hamstring complex.  Orthopedics. 2008;  31 1-8
  PubMedGoogle Scholar
• 36 Sallay P, Friedman R, Coogan P, Garrett W. Hamstring muscle injuries among water skiers.  Am J Sports Med. 1996;  24 130-136
  CrossrefPubMedGoogle Scholar
• 37 Sarimo J, Lempainen L, Mattila K, Orava S. Complete proximal hamstring avulsions: A series of 41 patients with operative treatment.  Am J Sports Med. 2008;  36 1110-1115
  CrossrefPubMedGoogle Scholar
• 38 Schlonsky J, Olix M. Functional disability following avulsion fracture of the ischial epiphysis: report of two cases.  J Bone Joint Surg Am. 1972;  54 641-644
  PubMedGoogle Scholar
• 39 Servant C, Jones C. Displaced avulsion of the ischial apophysis: a hamstring injury requiring internal fixation.  Br J Sports Med. 1998;  32 255-257
  CrossrefPubMedGoogle Scholar
• 40 Slavotinek J, Verrall G, Fon G. Hamstring injury in athletes: using MR imaging measurements to compare extent of muscle injury with amount of time lost from competition.  Am J Roentgenol. 2002;  179 1621-1628
  CrossrefPubMedGoogle Scholar
• 41 Stradley S, Backs R, Grosel J, Kaeding C. Hamstring avulsion repair without using a flexion splint.  J Am Acad Physician Assist. 2008;  21 33-37
  PubMedGoogle Scholar
• 42 Witvrouw E, Danneels L, Asselman P, D’Have T, Cambier D. Muscle flexibility as a risk factor for developing muscle injuries in male professional soccer players: A prospective study.  Am J Sports Med. 2003;  31 41-46
  CrossrefPubMedGoogle Scholar
• 43 Wood D, Packham I, Trikha S, Linklater J. Avulsion of the proximal hamstring origin.  J Bone Joint Surg Am. 2008;  90 2365-2374
  CrossrefPubMedGoogle Scholar
• 44 Wootton J, Cross M, Holt K. Avulsion of the ischial apophysis.  J Bone Joint Surg Br. 1990;  72B 625-627
  PubMedGoogle Scholar

Correspondence

Dr. Joshua D HarrisMD 

The Ohio State University

Orthopaedics

2050 Kenny Road

43221 Columbus

United States

Phone: +1/614/293 2663

Fax: +1/614/293 4755

Email: Joshua.Harris@osumc.edu