A 49-year-old male recreational player presented two weeks after an injury to his left hamstring. He described having lunged forwards with his left leg to contest a ball. He felt a tearing sensation in his proximal hamstring and was unable to continue. He did not develop any significant bruising. Since the injury he had experienced ongoing pain around the proximal hamstring, had difficulty striding out and felt pain with sitting. Of note this player had a history of multiple prior hamstring injuries, but none involving the proximal tendon.
On examination the proximal hamstring tendon was tender to palpation however it was clinically intact. He had pain with a straight leg raise and this was limited to 40 degrees (compared to 80 degrees on the contralateral side). There was also pain and some weakness with resisted hamstring testing on the symptomatic side.
An x-ray series of the hip and pelvis was normal. An MRI shows that the biceps femoris tendon has torn from its ischial origin and is retracted by about 3cm. The tendon stump is thickened and of intermediate signal. There is mild feathery oedema surrounding the tendon in the proximal fibres of biceps femoris muscle. There is oedema fluid surrounding the sciatic nerve adjacent to the biceps femoris stump. There is mild oedema in the lateral fibres of the proximal semitendinosus muscle. There is mild tendinosis and a small intrasubstance tear in the origin of semimembranosus and semitendinosus.
This player elected to pursue a non-operative rehabilitation programme. It was explained that the injury would behave differently to the injuries that he had previously experienced (that did not involve the proximal tendon) and that it may take at least twice as long to heal. He was managed with a progressive strengthening programme. While working on this rehabilitation he also started a walking programme and began jogging at approximately 6-8 weeks after his injury. Over a four-month period (from the time of injury) he progressed his strengthening, rehabilitation and running and was able to resume football training. At this stage he had no residual symptoms, had normal hamstring strength and reported that his “hamstring felt normal”. He has since completed a season of ‘masters’ football with no recurrence and no reported impairment.
The optimal treatment for an isolated rupture of one (of the three) proximal hamstring tendons is not known. Where there is a complete rupture of the proximal hamstring group surgical treatment is clearly the best option for younger, active patients. There is no good data to guide treatment decisions where there is a more isolated or partial injury. In an elite player surgical treatment may be considered as it could be argued that this will give a more predictable outcome in terms of restoring normal strength and function. In a more recreational player, as this case illustrates, a less aggressive treatment pathway can give good results. If these players do not get a good result from this type of non-operative treatment protocol delayed surgical repair is an option and has been shown to have good clinical results.
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