Hamstring injuries

Abstract

There is a continuum of hamstring injuries that can range from musculotendinous strains to avulsion injuries. Although the proximal hamstring complex has a strong bony attachment on the ischial tuberosity, hamstring injuries are common in athletic population and can affect all levels of athletes. Nonoperative treatment is mostly recommended in the setting of low-grade partial tears and insertional tendinosis. However, failure of nonoperative treatment of partial tears may benefit from surgical debridement and repair. The technique presented on this article allows for the endoscopic management of proximal hamstring tears and chronic ischial bursitis, which until now has been managed exclusively with much larger open approaches. The procedure allows for complete exposure of the posterior aspect of the hip in a safe, minimally invasive fashion.

Fig. 1.

(A) Cadaveric dissection of the ischium in a left hip, viewed from the posterior aspect. The arrow points to the origin of the Biceps/Semitendinosus (B/ST), which has been elevated and retracted laterally. (B) Axial T2 weighted view depicting the anatomy of the hamstring origin in a left hip. SN: Sciatic Nerve; SM (origin of Semimembranosus); B: Biceps origin.

Fig. 2.

AP of pelvis showing bilateral bony avulsions of the ischial tuberosities in a 14-year-old athlete.

Fig. 3.

MRI views of a partial insertional tear with a sickle sign, indicating fluid in the ischial bursa. (A) A coronal view, T2-weighted view of a right hip showing the sickle sign (white arrow). IT: Ischial tuberosity. (B) Axial view, T2 weighted, showing both ischial tuberosities. Note the right side (black arrow) showing the sickle sign and the normal left side (white arrow).

Fig. 4.

Positioning of the patient in the prone position with the leg draped free. This is of a left hip, positioned prone.

Fig. 5.

Portals for endoscopic approach with the arthroscope in the medial portal. The shaver is in the distal portal.

Fig. 6.

Normal arthroscopic anatomy exposure in a left hip, viewed from the lateral portal. (A) Sciatic Nerve and lateral ischium. Note the tool entering from the medial portal. (B) Inferior ischium depicting the separate attachments of the semimembranosus (SM) and the common biceps and semitendinosus (BST).

Fig. 7.

The distal end of the ischium cleared of soft tissue. View is from the lateral portal and shows all of the soft tissue cleared from the hamstring sheath.

Fig. 8.

Incision of tendon to explore area of tearing and ischial bursa. (A) Initial knife incision at the most proximal end of the ischium. (B) Exposed detached lateral hamstring complex.

Fig. 9.

Debridement and exposure of lateral and inferior ischium, including the ischial bursa. (A) Lateral ischium debridement and preparation. Note the tool is serving to retract the detached tissue. (B) Ischial bursa prior to debridement. Note the hypertrophic villonodular tissue surrounding the shaver. (C). Final debridement of bursa. Note the exposed bony surface at the top of the image and the lack of villonodular tissue.

Fig. 10.

Repair of tendinous avulsion. (A) Prepared surface with suture passer in place. (B) Shuttle suture in place (arrow). Note the proximity of the sciatic nerve to the repair. (C) Final mattress sutures in place in the substance of the tendon. (D) Final tendon repair.