ABSTRACT:
Injuries to the proximal hamstring muscle complex are common in athletes and range
from strains to tendinous and bony avulsions. The lesion mechanism typically involves
an eccentric contraction of the hamstring muscles during abrupt hip hyperflexion with
the knee in extension. Low-speed injuries occur in high kicks and splits, whereas
tendon avulsions are common in high-speed activities, such as running and ballet.
Clinically, patients present with pain, subcutaneous hematoma, and, sometimes, a palpable
defect. Additional signs include limited knee extension and involvement of the sciatic
nerve. Diagnosis relies on ultrasonography, magnetic resonance imaging (MRI), and
radiography, and MRI is the standard test. Surgical treatment is indicated for complete
avulsions, especially in athletes, to prevent loss of strength and difficulty in returning
to sports. In the surgical technique herein described, we perform one or two transverse
incisions in the gluteal fold, depending on the tendon retraction, followed by fixation
with metal anchors. The postoperative period includes initial restriction, followed
by accelerated rehabilitation for return to sports by the twelfth week. Since 2019,
the technique has been applied to 13 patients, demonstrating good outcomes, without
reruptures and a postoperative Tegner score similar to the preoperative one.
Keywords: hamstring muscle; hamstring tendons; tendon injury.
RESUMO:
As lesões do complexo dos músculos isquiotibiais proximais são frequentes em atletase
variam de distensões a avulsões tendíneas e ósseas. O mecanismo de lesão geralmente
envolve contração excêntrica dos isquiotibiais durante hiperflexão abrupta do quadril
com o joelho estendido. Lesões de baixa velocidade ocorrem em chutes altos e espacates,
ao passo que avulsões tendíneas são comuns em atividades de alta velocidade, como
corrida e balé. Clinicamente, os pacientes apresentam dor, hematoma subcutâneo e,
em alguns casos, defeito palpável. Sinais adicionais incluem limitação na extensão
do joelho e comprometimento do nervo ciático. O diagnósticoé feito por ultrassonografia,
ressonância magnética (RM) e radiografia, sendo a RM o exame padrão. O tratamento
cirúrgico é indicado para avulsões completas, especialmente em atletas, e visa evitar
perda de força e dificuldades no retorno ao esporte. A técnica cirúrgica aqui descrita
utiliza uma ou duas incisões transversais na prega glútea, dependendo da retração
do tendão, com fixação por âncoras metálicas. O pósoperatório inclui restrição inicial,
seguida de reabilitação acelerada para retorno ao esporte a partir da décima segunda
semana. Desde 2019, a técnica foi aplicada em 13 pacientes, e demonstrou bons resultados
sem rerrupturas, com pontuação pósoperatória no escore de Tegner semelhante à do pré-operatório.
Palavras-chave: lesões dos tendões; músculos isquiossurais; tendões dos músculos isquiotibiais.
FIGURES
| Citation: Falotico GG, Scatigna BF. Surgical Repair of Proximal Hamstring Tendon Avulsion. 60(03):. doi:10.1055/s-0045-1810038 |
| Note: Study developed at the Hip Group of the Escola Paulista de Medicina, Universidade Federal de São Paulo, São Paulo, SP, Brazil. |
| Financial Support The authors declare that they did not receive financial support from agencies in the public, private or non-profit sectors to conduct the present study. |
|
Conflict of Interests The authors have no conflict of interests to declare. |
| Received: February 26 2025; Accepted: May 22 2025 |
INTRODUCTION
Injuries to the proximal hamstring muscle complex pose a challenge to physically-active individuals and competitive athletes. The severity of these injuries can range from strains to complete myotendinous ruptures, proximal hamstring tendon avulsions, and bone avulsions.1,2 The lesion mechanism usually involves eccentric contraction of the hamstrings secondary to abrupt hip hyperflexion with the knee in extension.3,4 Proximal hamstring myotendinous rupture typically occurs in low-speed injuries, such as high kicks, splits, and sliding tackles.3 In contrast, proximal hamstring tendon avulsions are frequent in high-speed activities, such as running, water skiing, or extreme range of motion in ballet.4
Clinically, the patients present with pain, subcutaneous hematoma, and, sometimes, a palpable defect along the hamstring tract.5 Additional signs include pain in knee extension in a sitting position, lack of hamstring muscle tension (bowstring sign), and contiguity-related involvement of the sciatic nerve, which may lead to motor and/or sensory deficits and neuropathic pain.6 Diagnostic confirmation relies on several imaging modalities, including ultrasound, magnetic resonance imaging (MRI), and conventional radiograph, to assess bone involvement. The MRI is the most frequent method for diagnosis.7
Complete tendon and bone avulsions represent a potential indication for surgical treatment, especially in competitive athletes, to avoid long recovery periods that could compromise their careers. Non-surgical treatment results in lower satisfaction rates, reduced hamstring muscle strength, and a lower likelihood of returning to preinjury sports levels. Postoperative care should prioritize initial protection of the repair, followed by an accelerated rehabilitation protocol for early return to sports at least 12 weeks after surgery.8,9
The present study aimed to describe an open-repair technique for complete tendon avulsions through a transverse incision in the gluteal fold for injuries with up to 5 cm of retraction and 2 transverse incisions for cases with tendon stump distal migration greater than 5 cm. The discussion on surgical treatment remains scarce in the Brazilian literature, and there is no technique commonly performed by Brazilian orthopedists.
TECHNICAL DESCRIPTION
The technique herein described is based on the experience with a series of 13 consecutive patients operated on by the same surgeons together (GGF and BFS). ►Table 1 shows epidemiological data, injury classification, and injury and follow-up times.
| Sex | Age (years) | Time since lesion | Sport | Classification | Preoperative Tegner score | Postoperative Tegner score | Follow-up time | Complications |
|---|---|---|---|---|---|---|---|---|
| Female | 27 | 11 weeks | Running | 3 | 7 | 7 | 42 months | None |
| Male | 22 | 3 weeks | Rugby | 2C | 10 | 10 | 33 months | None |
| Male | 46 | 7 weeks | Bodybuilding | 3 | 4 | 4 | 46 months | None |
| Male | 48 | 2 weeks | Running | 3 | 5 | 6 | 6 months | None |
| Male | 53 | 2 days | Water skiing | 3 | 6 | 6 | 22 months | None |
| Female | 16 | 4 weeks | Judo | 2C | 9 | 7 | 14 months | Granuloma in the suture thread, with surgical reapproach |
| Female | 43 | 6 weeks | Bodybuilding | 2C | 5 | Not available | 1 month | No acute complications |
| Male | 52 | 2 weeks | Soccer | 2C | 5 | Not available | 1 month | No acute complications |
| Female | 49 | 10 days | Cycling and bodybuilding | 3 | 6 | 6 | 60 months | None |
| Male | 34 | 12 weeks | Capoeira | 1B | 9 | 9 | 48 months | Pain recurrence with no signs of new lesion; the patient continued practicing sports |
| Male | 14 | 10 days | Basketball | 3 (avulsion fracture) | 7 | 7 | 24 months | Loosening with migration of synthesis material requiring revision - no intercurrences after the revision |
| Male | 30 | 8 weeks | Mixed martialarts (MMA) | 3 | 9 | 9 | 4 months | None |
| Male | 47 | 6 weeks | Olympic and artistic gymnastics | 2C | 9 | Not available | 1 month | None |
The mean age of the patients was of 37(±13.2) years, ranging from 14 to 53 years. Regarding sex, there were 9 (69.2%) male patients. In total, 7 patients (53.8%) presented complete tendon avulsion and retractions greater than 2 cm (type-3 injury).
We used the Forlizzi et al.10(2022) classification to describe injuries as types 1A, 1B, 2C, 2S, and 3 (Appendix 1). The Tegner score (Appendix 2), a widespread functional assessment scale in orthopedics and physiotherapy, was used to measure physical and sports activity levels to assess sports performance. Tegner and Lysholm11 developed this tool in 1985 as a complement to the Lysholm score to evaluate the ability to return to sports and work activities after knee injuries, but it is currently applied to other joints as well. The score ranges from 0 to 10, with 0 indicating inability to work or play sports resulting from a joint condition, and 10, participation in high-impact competitive sports (including professional soccer and rugby).
Technique
The patient remains in the prone position with protective pads on the chest and knee flexion at approximately 45° (to bring the stump closer and relax the sciatic nerve) under spinal anesthesia and sedation. The incision follows the gluteal fold and extends for 5 to 7 cm, depending on the patient’s muscle volume. After skin and subcutaneous tissue opening, we identify and dissect the gluteus maximus fascia to avoid injury to the posterior femoral cutaneous nerve. After opening the fascia and protecting the nerve, we identify the tendon stump and handle it with care due to its proximity to the sciatic nerve. After identifying the tendon, we perform digital neurolysis of the sciatic nerve and isolate the stump for later repair. Ischial tuberosity scarification provides better tendon healing. We routinely use three 5.5-mm metal anchors to mimic the original footprint of the tendon (1 anchor for the semimembranosus tendon and 2 for the conjoint tendon) in continuous sutures and anchoring per the Krackow method.
In cases with significant retraction (greater than 5 cm after patient positioning) and injury time longerthan3 weeks, we can add a second transverse incision over the tendon stump projection to release the fibrosis and facilitate tendon sliding to the proximal region, minimizing the risk of sciatic nerve injury.
The incision is closed in layers, as is usual in other procedures. The postoperative period should respect suture protection, using a partial weight-bearing protocol with crutches for 2 weeks and restricting combined hip flexion and knee extension movements. It is possible to accelerate rehabilitation after the fourth week and allow the return to sports by the twelfth week.
Figures 1 to 9 and ►Videos 1-3 to 4 illustrate the surgical steps.
Video 1
Test after metallic anchor insertion. Online content including video sequences viewable at: https://www.thieme-connect.com/products/ejournals/html/10.1055/s-0045-1810038.
Video 2
Tendon suture. Online content including video sequences viewable at: https://www.thieme-connect.com/products/ejournals/html/10.1055/s-0045-1810038.
Video 3
Jumping activity during rehabilitation. Online content including video sequences viewable at: https://www.thieme-connect.com/products/ejournals/html/10.1055/s-0045-1810038.
Video 4
Strengthening of the hip muscles during rehabilitation. Online content including video sequences viewable at: https://www.thieme-connect.com/products/ejournals/html/10.1055/s-0045-1810038.
FINAL COMMENTS
We have been using this technique since 2019, performing surgical repair in 13 patients during this period. The surgery has proven to be reproducible, resulting in good clinical outcomes, with no cases of re-rupture to date and a postoperative Tegner score similar to the preoperative one. As the Shapiro- Wilk test showed that the data did not present normal distribution, we used the nonparametric Wilcoxon test for paired samples. This test revealed a mean preoperative Tegner score of 7.1 ± 1.97 and a mean postoperative Tegner score of 7.0 ± 1.83 (p = 0.72), demonstrating good sports recovery capacity.
The usual surgical technique for patients with retractions greater than 5.0 cm is a longitudinal incision, a wide approach with a higher potential risk of suture dehiscence. The transverse technique presented here, with one or two incisions, is feasible and an alternative for the surgical treatment of proximal hamstring injuries.
The main surgical indications included complete tendon avulsion or conjoint tendon avulsion with retraction greater than 2 cm in physically-active patients under 65 years old.
REFERENCES
