Abstract
Introduction
The management of proximal hamstring tear (PHT) is debated and consensus regarding recommended measures and individual treatment regimens is lacking. The present investigation evaluated the efficacy of a conservative management of partial and complete PHT.
Methods
The present observational study was conducted following the STROBE statement. In June 2018 the medical databases of the BG Klinikum Bergmannstrost Halle, Germany were accessed. All the patients with PHT were retrieved. The outcomes of interest were to evaluate the clinical examination, PROMs, imaging, and isokinetic muscle strength at the baseline and last follow-up.
Results
31 patients were enrolled in the present study. Nine patients (29 % (9 of 31) described local pain at the ischial tuberosity in sitting situations and also in manual palpation. A persistent gap in the tendon string beneath the tuberosity in manual palpation was reported in 25.8 % (8 of 31). The mean VAS at the last follow-up was 2.3 ± 2.3. The mean LEFS score was 50.9 ± 18.8.
Control MRI at follow-up showed scarring restitution in the proximal tendon in all patients in the partial tear group. In the complete tear group, a persisting defect state of the proximal tendon course was found in 45 % (9 of 20). The injured side achieved 81.5 ± 22.2 % of the force of the uninjured side, measured in the flexion movement at 60°/s. At an angular velocity of 240°/s, 83.2 ± 26.3 % of the force of the uninjured side was achieved.
Conclusion
According to the main findings of the present study, conservative therapy of PTH tears is associated with good clinical outcomes. High-quality investigations are required to establish the proper therapeutic algorithm and advantages of conservative management compared to a surgical approach.
Level of evidence
Level III.
Keywords: Ischiocrural, Hamstring, Isokinetic force, Management
Highlights
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•
The management of proximal hamstring tear is debated and consensus regarding recommended measures and individual treatment regimens is lacking.
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Conservative therapy of proximal hamstring tear tears is associated with good clinical outcomes.
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High-quality investigations are required to establish the proper therapeutic algorithm and advantages of conservative management.
1. Introduction
Proximal hamstring tears (PHT) can lead to a severe reduction in the quality of life.1,2 Approximately 12 % of all muscle injuries affect the hamstring complex (semitendinosus, semimembranosus, and biceps femoris), mostly at their musculotendinous junction.3,4 A distinction is made between complete and partial tear,5 which accounts approximately for 9 % and 3 %, respectively of PHT.6,7 Most of the affected patients are high-performance practitioners, aged 20 to 70.8, 9, 10 However, the number of injuries among people with normal activity levels, especially in everyday working life, has increased.11,12 Forced extension of the knee joint with simultaneous flexion of the ipsilateral hip joint leads to overstretching of the hamstring and might cause avulsion injuries.13,14 This can occur either during the sprint or jump phase or through uncontrolled slipping of the foot forward.15,16 Diagnosis and treatment of PHT are commonly based on anamnesis, clinical examination, and imaging. Magnetic resonance imaging (MRI) demonstrates high sensitivity to detect the site of a tear and the extent of tendon retraction.17,18
The management of proximal hamstring tendon tear is debated and consensus regarding recommended measures and individual treatment regimens is lacking.19, 20, 21 Refixation of the tendons with suture anchors is commonly used in PHT.22,23 Previous investigations found that prompt surgical management of PHT leads to superior outcomes to conservative regimes.20,24 However, surgery can be challenging and complications, including paresthesia, pressure sensitivity at the surgical site, and loosening or tearing of suture anchors are reported.25, 26, 27 The current literature lacks of investigation which analyses the outcomes of conservative regimes.28, 29, 30 At our institution, in patients with acute PHT, conservative management is recommended. The conservative management starts with rest, cryotherapy, analgesia, and progressive weight-bearing.31,32 Subsequently, intensive physiotherapy focused on stretching the ischiocrural muscles and improving muscular strength and proprioception.33,34
The present investigation evaluated the efficacy of conservative management of partial and complete PHT. The outcomes of interest were to evaluate imaging, clinical examination, patient-reported outcome measures (PROMs), and isokinetic strength evaluation at baseline and follow-up.
2. Methods
2.1. Study design
The present observational study was conducted following the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement: guidelines for reporting observational studies.35 In June 2018 the medical databases of the BG Klinikum Bergmannstrost Halle, Germany were accessed. All the patients with PHT were retrieved. The inclusion criteria were: (1) isolated PHT; (2) no severely restrictive mobility deficit; (3) age older than 18 years. The exclusion criteria were: (1) Preexisting relevant functional deficit of the lower extremity (e.g. fractures, congenital or acquired deformities, underlying neurological diseases, spinal nerve disorders); (2) Concomitant injuries to the lower extremity (3) Distal hamstring tendon tears; (4) previous hamstring surgery. The present study was conducted according to the principles of the Declaration of Helsinki and was approved by the ethics committee of the Medical Association of Saxony-Anhalt (EK 68/17). All patients firmed written consent and willingness to participate in the present study.
2.2. Patient management
Patients who presented at our institution, irrespective of their participation in the present study, were treated with intravenous paracetamol 1000 mg and ibuprofen 600 and pantoprazole 20 mg orally. If available, patients underwent MRI imaging. If not available, an outpatient MRI within 48 h was arranged. The conservative management of PHT involved analgesia with ibuprofen 600 twice daily, pantoprazole 20 mg once daily, compression therapy, thrombosis prophylaxis with weight-adapted enoxaparin, and immobilisation of the affected leg. After one week, the patients were clinically re-evaluated and referred to a physiotherapy centre. Patients started manual therapy, ultrasound, and lymphatic drainage within the first four weeks. From the fifth week, more intensive physiotherapy began, initially with a focus on normalization of the gait pattern, followed by neuromuscular control. At the end of the eighth week, exercises to strengthen and stretch the thigh muscles were recommended to improve endurance and harmonize the gait pattern. After normalization of the gait pattern, patients started an individualised structured program to improve sport-specific movement patterns.
2.3. Outcomes of interest
On admission, the following data were recorded: age, gender, BMI, cause of injury, and time elapsed from the injury to the first consultation. Imaging, clinical examination, PROMs, and isokinetic strength evaluation were performed at baseline and follow-up.
The outcomes of interest were to evaluate the clinical examination, PROMs, imaging, and isokinetic muscle strength at the baseline and last follow-up. The clinical evaluation included the examination of the proximal tendon course for pressure dolence in the area of the tuber ischiadicum and a palpable gap below the tuber ischiadicum. The presence of peripheric neurologic deficit and motion restriction were also assessed.
The following PROMs were administered: Visual Analogue Scales (VAS) and Lower Extremity Functional Scale (LEFS).
Each patient underwent an MRI (Philips MR Ingenia 3.0 T, Philips Healthcare, Hamburg, Germany) of both upper legs up to the hip joint with coronary-STIR-sequence, sagittal T1w-TSE-sequence, sagittal and transversal T2w-TSE-sequences, and transversal Dixon Quant-sequence. MRIs were performed at baseline and follow-up and evaluated by the attending physician and two senior radiologists specialising in trauma radiology. At baseline, the affected muscle tendons were documented and the initial retraction distance of the tendon was measured as the distance between the tendon stump and the ischial tuberosity. Based on these results, the injuries were categorized according to the Wood classification17 (Table 1).
Table 1.
Wood-Classification of proximal tendon tears of the ischiocrural muscles.
| Degree | Description |
|---|---|
| I | Apophyseal avulsion in skeletally immature patients |
| II | Musculotendinous tears |
| III | Incomplete bony avulsion |
| IV | Complete bony avulsions with no or minimal retraction |
| V | Complete bony avulsions with retraction |
| a | Non associated with isciatic nerve injury |
| b | Associated with ischiatic nerve injury |
The evaluated criteria at follow-up included the extent of tendon retraction and signs of fibrous remodelling. The cross-sectional measurement of the ischiocrural musculature was compared with the non-affected side at the same distance to the ischial tuberosity in transversal T1 sequences to determine possible atrophy. The grade of fatty degeneration was described in Grades of Goutallier36 (Table 2).
Table 2.
Semiquantitative classification of fatty degeneration according to Goutallier.
| Grade | Criteria |
|---|---|
| 0 | Regular muscle without fatty infiltration |
| 1 | Musculature with few fatty streaks |
| 2 | Fatty infiltration, but more muscle than fat |
| 3 | Equal proportions of muscle and fat |
| 4 | Proportion of fat greater than proportion of muscle |
Isokinetic hamstring strength was measured using the Biodex S4 System (Biodex Medical Systems Inc., Shirley, New York, USA, Fig. 1). The isokinetic force measurement was carried out for both extremities with three repetitions at 60°/s and twelve repetitions at 240°/s. The results were registered in the Biodex software. The maximum torque in flexion was used to calculate the percentage force of the injured side compared to the healthy side for the angular velocities of 60°/s and 240°/s, respectively. The hamstring-to-quadriceps ratio (H/Q ratio) was calculated using the ratio between the maximum torque of the flexors and the maximum torque of the extensors at an angular velocity of 60°/s and 240°/s. The evaluation of the data takes place in a side comparison between the injured and uninjured sides.
Fig. 1.
Isokinetic strength using the Biodex S4 System.
2.4. Statistical analysis
All statistical analyses were performed using the software IMB SPSS version 24.0. Continuous data were analysed using the mean difference (MD), while for dichotomic data, the odds ratio (OR) effect measures were calculated. The confidence interval was set at 95 % in all the comparisons. The t-test Mann-Whitney-U-test and Wilcoxon test were performed, with values of p < 0.05 considered statistically significant.
3. Results
3.1. Recruitment process
A total of 53 patients with a proximal tear of the ischiocrural tendons were initially included. A further 19 patients were excluded: acute femur fracture (N = 1), not wish to be included in the study (N = 4), and missing contact data (N = 14). This left 34 eligible patients. At the last follow-up, 8.8 % (3 of 34) were excluded as they received a surgical refixation of the tendons using suture anchors. Finally, 31 patients were enrolled in the present study (Fig. 2).
Fig. 2.
Diagram of the recruitment process.
3.2. Patient demographics
68 % (21 of 31 patients) were women. 55 % (17 of 31 patients) injured their right side. The mean age of the patients was 57.9 years and the mean BMI was 28.5 kg/m2. The mean follow-up was performed at 35.8 ± 21.2 months after trauma. Table 3 reports the demographic data of the patients on admission and Table 4 the activity which led to the injury.
Table 3.
Demographic data of patients at baseline.
| Endpoint | Value |
|---|---|
| Follow-up (month) after trauma | 35.8 ± 21.2 |
| Age (y) | 57.9 ± 7.0 |
| Women (%) | 67.7 (21 of 31) |
| BMI (kg/m2) | 28.5 ± 5.3 |
| Time from injury to first consultation (d) | 35.5 ± 67.0 |
| Time from injury to first MRI (d) | 17.9 ± 25.0 |
| Return to work (%) | 80.6 (25 of 31) |
| VAS | 6.7 ± 1.7 |
| LEFS | 75.6 ± 5.8 |
| Wood | |
| Grade 3 | 32.2 (10 of 31) |
| Grade 4 | 19.4 (6 of 31) |
| Grade 5 | 48.4 (15 of 31) |
Table 4.
Cause of injury.
| Cause of injury | Value (%) |
|---|---|
| Slipping on a slippery surface | 61.3 (19 of 31) |
| - Of them with splits | 36.8 (7 of 19) |
| Trip and fall | 12.9 (4 of 31) |
| Riding a bicycle | 6.5 (2 of 31) |
| Skiing | 3.2 (1 of 31) |
| Water skiing | 3.2 (1 of 31) |
| Playing soccer | 3.2 (1 of 31) |
| Running in everyday life | 3.2 (1 of 31) |
| Traffic accident | 3.2 (1 of 31) |
| Not remembered | 3.2 (1 of 31) |
3.3. Evaluation of the clinical and subjective outcome
All complete tears showed a persistent gap in the tendon string beneath the tuberosity in manual palpation. In the comparison between partial and complete tears, there were no significant differences in the frequency of pressure dolence above the tuber ischiadicum (p = 0.2). A palpable gap below the tuber ischiadicum was only detectable in patients with a complete tear (p = 0.03). One patient with a complete tear reported a neurologic motor dysfunction in the form of weakness of the extensor hallucis longus muscle (strength grade 3/5 according to the Janda method), but none of the patients with partial tears. The mean VAS at the last follow-up was 2.3 ± 2.3. The mean LEFS score was 50.9 ± 18.8. The main results of the last follow-up are shown in Table 5.
Table 5.
Main results at last follow-up.
| Endpoint | Value |
|---|---|
| VAS | 2.3 ± 2.3 |
| LEFS | 50.9 ± 18.8 |
| Pressure dolence (%) | 29.0 (9 of 31) |
| Gab below the tuber ischiadicum (%) | 25.8 (8 of 31) |
| Sensible neurological deficit (%) | 0 (0 of 31) |
| Motoric neurological deficit (%) | 3.2 (1 of 31) |
| Strength deficit (in 60°/s flexion) (%) | 81.5 ± 22.2 |
| Strength deficit (at angular velocity of 240°/s) (%) | 83.2 ± 26.5 |
| HQ-Ratio at 60°/s injured side (%) | 50.1 ± 10.4 |
| HQ-Ratio at 60°/s uninjured side (%) | 56.1 ± 10.9 |
3.4. Evaluation of the magnetic resonance imaging
Follow-up MRI was completed by 96.7 % (30 of 31) patients: 66.7 % (20 of 30) complete and 33.3 % (10 of 30) partial PHT. At follow-up, 70.0 % (21 of 30) of patients present scarred restitution with fully restored tendon fibre continuity. 30 % (9 of 30) of patients present a measurable defect section in the tendon on the ischial tuberosity. In addition, fluid retention was visible on the injured side in 20 % (6 of 30) of the image morphology follow-up examinations. Control MRI at follow-up showed scarring restitution in the proximal tendon in all patients in the partial tear group. In the complete tear group, a persisting defect state of the proximal tendon course was found in 45 % (9 of 20).
3.5. Evaluation of the isokinetic force measurement
The force measurement was completed by 90.3 % (28 of 31) patients. The maximum torques of the flexion movement in the knee joint at 60°/s and 240°/s were assessed in a side-by-side comparison. The injured side achieved 81.5 ± 22.2 % of the force of the uninjured side, measured in the flexion movement at 60°/s. At an angular velocity of 240°/s, 83.2 ± 26.3 % of the force of the uninjured side was achieved. No significant difference was found in the comparison between the percentage force in the side comparison at the slow angular velocity of 60°/s and the percentage force in the side comparison at the fast angular velocity of 240°/s (p = 0.5).
4. Discussion
According to the main findings of the present investigation, conservative therapy of PTH tears is associated with good clinical outcomes.
Unfortunately, there is a lack of high-quality comparative studies evaluating the conservative management of PHT tears. We were able to identify only a few investigations with limited sample size and lack of standardised diagnostics (MRI and/or LEFS) which evaluated the outcomes of conservative management of PHT tears.28,29,32,37
Despite little high-level supporting evidence, PHT tears are increasingly treated surgically. Previous systematic reviews compared conservative versus surgical management of PHT tears.20,26,38 The outcome of surgery versus non-surgical management of proximal hamstring tendon avulsions has been previously assessed through a systematic review. Harris et al.38 found that a surgical approach was associated with better subjective outcomes, a greater rate of return to pre-injury level of sport, and greater strength/endurance. Similarly, van der Made et al.26 observed that surgical management was associated with a subjective higher satisfying outcome. Bodenforfer et al.20 also evidenced that the surgical approach was associated with superior outcomes compared to conservative management. All three reviews reported a low re-rupture rate in favour of the surgical repair (2.7 %, 3.0 %, and 2.2 %, respectively).
The results relating to conservative treatment management of PHT in the current study are not consistent with previous investigations. Especially in the LEFS, no significant difference between surgical and conservative management was reported.32,37 One explanation for this deviation is a potential bias in comparability with the results of the surgical studies. Patients in the present study were significantly older compared to previous studies on the surgical management,20,39 but this is consistent with previous evidence on the conservative management.20,28,32 Whether the decline in physical performance capacity in the elderlies might influence the outcome and between studies comparability is undetermined.40 Injuries in the current study occurred mainly during everyday activities, whereas in most previous studies sports accidents are reported as the main cause.7,13,17,39,41 Subjective scores of this study resulted in a LEFS of 50.9 points, which is remarkably lower than the average reported in articles on surgically treated patients (range 70–76 points)20,26 and conservatively managed patients (range, 64 to 70).28,29,32,37 Moreover, the validity of the LEFS for PHT tears has been questioned.42
Subgroup analysis of this study compares the complete tears (Wood type IV and V) with the partial tears (Wood type III) of the study population. Patients with complete tears reported worse results in LEFS (43.6) and isokinetic strength at 60°/s (73.6 %), compared to patients with partial tears (LEFS = 66.2; strength at 60°/s = 95.7 %). Similar results regarding LEFS and isokinetic strength in partial tears have also been reported by previous investigations focusing on conservative PHT procedures.29 In addition, the partial tears reached 94 % of the previous activity level but only 64 % for the complete tears, which has also been evidenced in previous evidence.13
We acknowledge several strengths and limitations within our study. The limited sample size and the retrospective design increase the selection bias. Further, only 64 % of the patients with PHT tears who were treated were recruited for follow-up. The high rate of patients lost at the follow-up was also impaired by the COVID-19 pandemic outbreak, which imposes challenges on outpatient examinations and travelling for research purposes. Moreover, it is unclear whether individual physiotherapeutic regimes might impact the outcome of conservative management. Recommendations on the conservative management of proximal hamstring avulsion injuries are lacking, with missing indications of rehabilitation and unpredictable results.43 There is limited evidence which considers the physiological activation patterns of the hamstrings, for example, hip- or knee-based strength training exercises.43, 44, 45 Furthermore, isokinetic strength was not performed in three patients with complete tears due to persistent discomfort. Finally, conservative management of PHT might also be associated with complications. Early functional rehabilitation can lead to further retraction of the muscle bundle, especially in patients with complete rupture, even despite the initially limited mobilisation of the affected leg, resulting in a poorer functional outcome. In the case of partial ruptures, there is also a risk that intact parts of the tendon may rupture secondarily, resulting in a complete rupture. Further high-quality studies should compare the results of conservative versus surgical management according to the different Wood stages to identify the proper therapeutic algorithm.
5. Conclusion
Conservative management of PTH tears might be associated with good clinical outcomes. High-quality investigations are required to establish the proper therapeutic algorithm and advantages of conservative management compared to a surgical approach.
Funding/sponsorship
None.
Ethical statement
The present study was conducted according to the principles of the Declaration of Helsinki and was approved by the ethics committee of the Medical Association of Saxony-Anhalt (EK 68/17).
Funding
No funding was received for this research.
Guardian/Patient's Consent.
All patients firmed written consent and willingness to participate in the present study.
CRediT authorship contribution statement
Thomas Mendel: Conceptualization, Investigation, Methodology, Resources, Visualization, Writing – original draft. Mark Steinke: Writing – review & editing. Philipp Schenk: Data curation, Formal analysis, Investigation, Methodology, Writing – original draft, Sophia Leven: Methodology. Filippo Migliorini: Writing – review & editing. Vincent Schütte: Writing – review & editing. André Reisberg: Supervision. Philipp Kobbe: Conceptualization, Funding acquisition, Project administration, Resources, Software, Supervision, Writing – review & editing. Markus Heinecke: Conceptualization, Project administration, Resources, Software, Supervision, Writing – review & editing.
Acknowledgements
none.
Contributor Information
Thomas Mendel, Email: dr.th.mendel@gmail.com.
Mark Steinke, Email: steinkemarc@web.de.
Philipp Schenk, Email: philipp.schenk@bergmannstrost.de.
Filippo Migliorini, Email: migliorini.md@gmail.com.
Vincent Schütte, Email: vincentschuette@hotmail.com.
André Reisberg, Email: andre.reisberg@martha-maria.de.
Philipp Kobbe, Email: philipp.kobbe@bergmannstrost.de.
Markus Heinecke, Email: Markus.heinecke1@googlemail.com.
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