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Proximal hamstring tendon injuries are serious conditions that primarily affect athletes but can also occur in the general population. These injuries involve the detachment of the hamstring tendons from the ischial tuberosity. (the bone you sit on).
The proximal hamstring complex consists of the agglomeration of three tendons: Semimembranosus Tendon: Inserted on the upper lateral part of the ischial tuberosity. Semitendinosus and Biceps Tendons: These two tendons combine to form the conjoint tendon, which also inserts on the ischial tuberosity next to the semimebranosus. This group of three tendons forms a complex that is crucial for movements such as running, jumping, and various other athletic activities.
These injuries can be partial, involving one or two tendons, or complete, involving all tendons. They may be retracted to the thigh or not. Additionally, they may or may not cause irritation of the sciatic nerve in the posterior thigh.
Common symptoms include sudden, severe pain in the buttock area, bruising, and difficulty walking or sitting. Each type can be managed differently.
Accurate diagnosis typically requires an MRI, which provides detailed imaging of the tendons and helps guide treatment decisions.
Ultrasound can be an ulternative if performed by an expert in the field.
Can be conservative or surgical depending on the type of injury, tendon retraction and associated conditions.
At Chirurgie du Sport, we offer a comprehensive approach to diagnosing and treating proximal hamstring tendon injuries. Our team of experts, led by Dr. Nicolas Lefèvre and his associated expert surgeons Dr. Alexandre Hardy, Dr. Yoan Bohu, Dr. Alain Meyer, and Dr. Olivier Grimaud, employs the latest techniques to ensure the best possible outcomes for our patients. Our techniques are continuously improved and developed, and our results are regularly evaluated with follow-ups.
We proudly offer more than 20 years of experience in the field, with over 1,100 hamstring operations performed by June 2024, and regularly followed patients through an internationally registered cohort: the PHAS cohort. This is the largest hamstring cohort yet established in the world.
Our commitment to excellence is backed by our dedicated research unit. This scientific unit evaluates our treatment methods and outcomes, ensuring continuous improvement and the highest standards of care. Our research findings are regularly published in leading medical journals, contributing to the global body of knowledge on hamstring injuries. Click here to learn more about
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Q: What is the range of severity of proximal hamstring injuries?
These injuries vary in severity, ranging from simple strains to complete tears of the proximal hamstring tendons, tendon avulsions, and bone avulsions at their insertion on the ischial tuberosity.
An avulsion is when a tendon is forcibly detached from its bone insertion. Acute avulsions happen suddenly, often from a traumatic event or high-impact activity. Avulsions can occur during sudden hip flexion while the knee is hyperextended, such as in runners, football players, or during forceful knee extension in rugby. Climbers can also experience avulsions during propulsion movements.
Tendinopathy is the degeneration of tendon tissue due to overuse and inflammation. It causes pain and impaired function but does not involve rupture or detachment. Tendinopathy injuries develop gradually due to repetitive stress and overuse.
Tendon tears involve a disruption in the tendon. These tears can occur at the bone origin (avulsion) or at a few centimeters away from the insertion. It can involve one or more tendon.
The injury mechanism generally involves an eccentric contraction of the hamstring muscles due to a sudden and powerful hip flexion while the knee is extended or hyperextended. Free tendon injuries are often associated with low-velocity incidents, such as splits, sliding tackles, and high kicks. More proximal and myotendinous injuries occur during high-velocity activities like running, water skiing, or extreme ballet positions. Artistic gymnastics and ballet can lead to semimembranosus ruptures due to hyperextension movements.
Symptoms include pain, subcutaneous hematoma, and sometimes a palpable defect along the hamstring muscles. Other symptoms may include an avoidance of hip flexion when the knee is extended, a lack of hamstring muscle tension, and sciatic nerve-related issues such as motor and sensory deficits and neuropathic pain.
Additionally, we have described the “Cluster of Chair Signs,” which are typical for patients presenting in the acute phase with high sensitivity and specificity.
Another sign includes the “paillasson sign,” where patients experience pain when trying to mimic the motion of wiping their shoes on a doormat.
Click here to read our publication to answer this question.
Imaging should be done as soon as the diagnosis of hamstring injury is suspected.
Several types of imaging can help confirm the diagnosis, including ultrasound, MRI, and standard X-rays if there’s bone involvement. We recommend MRI as the first choice because it provides detailed images and helps us quickly determine the best treatment plan. Getting an MRI early can lead to faster access to surgery if needed, which improves healing and recovery.
Click here to read our reference publication to answer this question.
When indicated, we recommend surgery within 32 days of the injury can significantly reduce the risk of recurrence and lead to better functional outcomes.
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Several questionnaires can be used for this purpose, including the Tegner Activity Scale, UCLA Activity Scale, Lower Extremity Functional Scale, 12-Item Short Form Health Survey, visual analog scale for pain, Perth Hamstring Assessment Tool (PHAT), and Single Assessment Numeric Evaluation.
At Chirurgie du Sport, we have designed our own questionnaire – The Parisian Hamstring Avulsion Score (PHAS), specifically for our patients and validated internationally. The PHAS is scored out of 100 and allows you to track your progress and achievements.
Click here to read our reference publication to answer this question.
Return to sport typically occur within 12 to 16 weeks.
The time it takes to return to full sports activity varies depending on the sport. On average, athletes can expect to return to full activity within a year after surgery. For example, gymnasts typically return in about 5.2 months, while those in combat sports might take around 8.9 months. Most athletes can get back to their sports within a year post-surgery.
Click here to read our reference publication to answer this question.
Click here to read our reference publication to answer this question.
Athletes who have undergone surgical treatment for proximal hamstring injuries can expect a very high return-to-sport rate. Up to 98.4% of operated professional athletes return to competition, with 78.1% reaching their pre-injury performance level within an average of 6.2 months. Factors that favor a successful return to sport include being male, having an isolated semimembranosus injury, and free tendon ruptures of the proximal hamstring tendons.
Click here to read our reference publication to answer this question.
Click here to read our reference publication to answer this question.
Not all avulsions need surgery. We usually recommend surgery for complete avulsions, partial avulsions with significant retraction (more than 2 cm), and cases that don’t improve after 6 months of conservative treatment. Traditionally, younger and more active individuals or athletes weee ideal candidates for surgery. However, recent findings suggest that even patients over 50 can benefit significantly from surgery.
Q: What is recommended for those not requiring surgery?
For patients not needing surgery, conservative treatment is beneficial. This includes rest, ice application, physical therapy to gradually restore range of motion and strength, and sometimes Platelet-Rich Plasma (PRP) injections. A structured rehabilitation program, typically lasting about 4-6 months, is essential. Regular follow-ups help monitor progress and adjust the treatment plan as needed.
The surgery involves reattaching the avulsed tendon to the bone using four suture anchors. We use a horizontal approach for acute injuries and a vertical approach for chronic and retracted tendons.
Click here to read our reference publication to answer this question.
Post-operative care includes wearing a hinged knee brace fixed at 30 to 50 degrees extension to protect the repair. Partial weight bearing with crutches begins within 24–48 hours.
This is followed by a structured rehabilitation program with early rehabilitation includes isometric exercises. Active rehabilitation starts after 6 weeks, with gradual progression to dynamic exercises and strengthening. Usual sports activities can be resumed between the 16th and 32nd weeks.
Click here to read our reference publication to answer this question.
The re-rupture rate is very low (4%). Most re-ruptures (75%) happen within the first 6 months after surgery. A study by our team identified two major risk factors: Chronicity (>32 days since injury): associated with 2.5 times increased risk. The best time for surgery, to reduce the risk of re-rupture, is within 32 days of the injury. Initial Complete Injury: associated with 4 times increased risk.
Other risk factors include poor surgical technique, inadequate rehabilitation, premature return to high-impact activities, and underlying health conditions affecting tendon healing.
Click here to read our reference publication to answer this question.
Surgery is usually considered when conservative treatments fail to relieve symptoms. We make the decision based on the severity of symptoms, impact on quality of life, and activity level.
Currently, the literature in this area is limited, and there are no comparative studies published yet. Patients who eventually need surgery do improve but tend to have more residual pain compared to those with avulsion injuries.
Patients with persistent or worsening symptoms despite conservative treatment should consider imaging at 3 months to assess progression and compare it to the initial MRI.
Patients can book consultations online through our clinic’s website chirurgiedusport.com or by calling our office. Both in-person and telehealth appointments are available depending on the patient’s preference and location.
Surgical technique for repair of acute proximal hamstring tears
https://www.sciencedirect.com/science/article/pii/S1877056812001466?via%3Dihub
In this study published in the OTSR journal, we detailed our surgical technique for repairing acute proximal hamstring tears, which involves using 2 to 4 suture anchors and post-operative bracing. We also outlined our post-operative protocol and rehabilitation process.
Returning to sports after surgical repair of acute proximal hamstring ruptures
https://link.springer.com/article/10.1007/s00167-012-2204-2
In this study published in the KSSTA journal, we evaluated the outcomes of athletes after surgical repair of acute proximal hamstring ruptures. Our findings showed that nearly 80% of patients returned to their pre-injury sports level within about 6 months, demonstrating the effectiveness of surgical intervention. Most patients maintained similar activity levels and reported high satisfaction with their recovery.
Predictors of Early Return to Sport After Surgical Repair of Proximal Hamstring Complex Injuries in Professional Athletes: A Prospective Study
https://journals.sagepub.com/doi/10.1177/03635465231225486
In this study published in the AJSM journal, we evaluated professional athletes who underwent surgical treatment for proximal hamstring complex injuries to identify factors that influence their return to sports. We found that 98.4% of athletes returned to competition, with 78.1% reaching their pre-injury performance level within an average of 6.2 months. The study identified three key predictors for a successful early return to sports: being male, having an isolated semimembranosus injury, and experiencing a complete proximal hamstring free tendon rupture.
Validation of the Parisian Hamstring Avulsion Score (PHAS) in the Evaluation and Follow-up of Patients Operated for Proximal Hamstring Avulsion
https://journals.sagepub.com/doi/10.1177/03635465241227434
In this study published in the AJSM journal, we validated a new assessment tool, the Parisian Hamstring Avulsion Score (PHAS), for evaluating patients after proximal hamstring avulsion (PHA) surgery. Our findings demonstrated that the PHAS is a reliable and valid measure for predicting return to sport and tracking recovery.
Risk Factors for Rerupture After Proximal Hamstring Avulsion Injury Including the Optimal Timing for Surgery
https://journals.sagepub.com/doi/10.1177/03635465241233734
In a study published in the AJSM journal, we looked at the rerupture rates and risk factors for repairing proximal hamstring avulsion injuries. We analyzed data from 740 patients treated between 2002 and 2022 and found a rerupture rate of 4.59%, with most reruptures happening within the first 6 months after surgery. The key risk factors for rerupture were waiting more than 32 days between the injury and surgery, and having an initial complete rupture. Our findings emphasize the importance of getting surgery early to reduce the risk of rerupture.
MRI as the First-Line Imaging Modality for Proximal Hamstring Avulsion Injuries
https://esskajournals.onlinelibrary.wiley.com/doi/10.1002/ksa.12258
In this study, we looked at how using MRI or ultrasound (US) first to diagnose proximal hamstring avulsion injuries affects the timing of surgery and recovery. We found that starting with an MRI leads to quicker surgeries and better recovery outcomes. Out of 392 patients, those who had an MRI first got surgery about 10 days sooner than those who had an ultrasound first. They also had better scores on activity scales, meaning they recovered more effectively and returned to their normal activities faster. This shows that using MRI as the first step can help ensure faster and better recovery for patients with this type of injury.
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