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Acute Proximal Hamstring Injuries Aaron J. Krych, MD Mayo Clinic Sports Medicine Associate Professor Director, Sports Medicine Fellowship Director, Sports Medicine Research Fellowship
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Diagnosis and Management of Acute Proximal Hamstring Tendon Injuries
• History and Exam - Aaron J. Krych, MD • Imaging - Mark S. Collins, MD • Surgical Repair - Indications and
Outcomes - Aaron J. Krych, MD • Non-operative & Post-operative Rehab -
Jeffrey D. Strauss, PT, DPT
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Disclosures • Consultant
• Arthrex, Vericel • Research Support
• Arthritis Foundation, Histogenics, Ceterix, Aesculap, Samumed
• Medical Board of Trustees • MTF
• Editorial Board • AJSM Social Media, MN Orthopedic Society
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History and Exam
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Anatomy • The hamstring is made up of 3
muscles: • Semitendinosus • Semimembranosus • Biceps femoris (long and
short head)
• All 3 innervated by sciatic nerve
• Semi-T and biceps make up conjoint tendon
• Semi-M more lateral long tendon
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Gluteus maximus
Hamstring muscles
Proximal
Distal
Medial Lateral
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Proximal
Distal
Medial Lateral
ST ligament
Adductor magnus tendon
Adductor magnus muscle
Conjoint tendon (Biceps femoris/semi-T)
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Proximal
Distal
Medial Lateral
ST ligament
Conjoint tendon (reflected from bone but partially in continuity with ST ligament)
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Proximal
Distal
Medial Lateral
Ischial tuberosity
Conjoint tendon (reflected)
Semimembranosous
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Function • Knee flexion • Hip extension • 70% fast twitch fibers (quad
50%) • Sprinting • Walking
• Late recovery phase • Provide eccentric control
and knee stability
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Acute Hamstring Tears: Etiology and Mechanism • 12% of hamstring injures involve a tear or
avulsion of the proximal hamstring origin, 9% of which are complete avulsions
• Injury involves a traumatic event with forced hip flexion and combined knee extension
Barnett KSSTA 2014
Dierckman Arthroscopy 2012
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Need to distinguish between hamstring “pull/strain” and avulsion
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History of Mechanism • Avulsions
• Athletes • Waterski, bull-riders,
“splits” • Non-athletes
• Slip on ice • Slip on wet floor
• Hamstring strains • Sprinting—eccentric force
on a lengthened muscle
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Commonly Presenting Symptom • Difficulty Sitting • Buttock Pain • Difficulty walking fast • Weakness • Sciatic nerve symptoms
• Pins and needles in sciatic distribution
• Rare foot drop
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Clinical examination • Dichotomy of presentations
• Doorway sign • Tenderness to palpation
• Localizes well • Strength deficits • Palpable defect • Bruising • Popeye sign
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Gold standard for diagnosis • MRI