Proximal hamstring tendon injuries are common, particularly among individuals in explosive sports or activities involving sudden bursts of speed. These injuries occur when one or more hamstring tendons at the back of the thigh become swollen (also known as tendinosis) or are partially or fully torn from their origin at the ischial tuberosity (the “sit bones”). It is critical to differentiate a tendon tear from tendinosis. So, how do we diagnose a proximal hamstring tendon tear, and how do we manage it?
Hamstring tendon anatomy
The hamstrings are a group of three muscles: the semitendinosus, semimembranosus, and biceps femoris. These muscles originate from the ischial tuberosity at the base of the pelvis and are inserted into different parts of the lower leg. The two proximal hamstring tendons attach the muscle group to the pelvis. When subjected to extreme stress, they can tear.
Proximal hamstring tear symptoms
The symptoms of a proximal hamstring tendon tear can vary depending on the severity of the injury (partial vs. complete tear):
- Partial tear of the proximal hamstring tendon is often characterised by sharp, sudden pain in the buttocks or upper thigh, difficulty sitting, swelling, and possible bruising along the back of the thigh. Some function remains, but activities like walking or bending the knee may be uncomfortable. However, sometimes, pain can have a gradual onset, occurring during or after an activity such as running or sports. In these cases, a partial tear can be like a tendinosis.
- Full tear of the proximal hamstring tendon generally occur after trauma from a fall or sports where the tendon is suddenly stretched. In addition to the above, we often see a visible deformity (a noticeable gap or dent at the site of the tear), bruising in the upper thigh, and an inability to bend the knee or extend the hip with significant leg weakness.
How to Diagnose Proximal Hamstring Tears
Diagnosis begins with an assessment, including a history of the injury mechanism and a physical examination. The doctor may find:
- Tenderness at the ischial tuberosity.
- Pain when contracting the hamstring muscles.
- Limited range of motion of the hip.
Your doctor must exclude other causes of acute buttock or thigh pain, such as a hamstring or gluteal muscle tear.
Imaging for torn proximal hamstring tendon
Imaging studies are crucial for confirming pathology.
- Ultrasound can visualise soft tissue injuries such as tendinosis or tear. However, generally, tears are more challenging to diagnose with ultrasound.
- Magnetic Resonance Imaging (MRI) is the gold standard for diagnosing proximal hamstring tears. It helps determine the degree of tearing (partial vs. complete), the amount of tendon retraction (in full tears), and the extent of surrounding tissue and nerve damage. MRI below demonstrates a significant partial interface tear.
Treatment
Treatment depends on whether the proximal hamstring tendon tear is partial or full-thickness.
Full proximal hamstring tears
Complete proximal hamstring tears, particularly those with tendon retraction from the bone, often require surgical repair for optimal recovery. Indications for surgery include:
- Complete detachment of the two tendons from the sitting bone (ischial tuberosity). In athletes, we consider an early repair when one of the two tendons is torn from the bone.
- More than 2 centimetres of tendon retraction.
- Persistent pain, weakness, or functional limitation despite conservative management.
Surgical Procedure
Surgery typically involves reattaching the torn tendon(s) to the ischial tuberosity using a suture. Due to the closeness of the large sciatic nerve, it is a delicate procedure.
Postoperative rehabilitation is crucial and generally follows a structured protocol:
- Initial Rest:
- The leg is often immobilised in a brace for several weeks to allow the tendon to heal securely. Weight-bearing is limited initially (4-6 weeks) using crutches.
- Gradual Rehabilitation:
- Early physical therapy focuses on restoring range of motion without overloading the tendon. Strengthening exercises are introduced progressively.
- Return to sports-specific activities is generally delayed for at least five months post-surgery.
Partial hamstring tendon tears
Partial or interface tears, where the tendon is still attached but damaged, are often managed without surgery. We treat these similarly to high hamstring tendinopathy.
Conservative treatment includes:
- Activity Modification:
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- Avoid activities aggravating the injury, such as running, jumping, or intense physical exertion.
- Physical Therapy:
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- Once the acute pain subsides, a progressive program focusing on strengthening exercises is essential.
- The focus of strengthening should be on building strength in the hamstring through various exercises, as outlined in this blog on proximal hamstring tendinopathy.
- Platelet-Rich Plasma (PRP) Injections:
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- PRP therapy involves injecting the patient’s concentrated platelets into the injury site to promote tissue healing. This has shown promise in accelerating recovery for tendon injuries, though evidence is still evolving.
- Generally, injection therapy should only be considered when non-injection options have failed. We would advise against early PRP injections.
- There is a lot of debate regarding the optimal PRP system for tendon damage. Generally, however, we consider a high-concentration PRP.
Other Frequently Asked Questions about Proximal Hamstring Tears:
What is the evidence for treating proximal hamstring tendon tears with PRP?
Generally, we use PRP injections for partial tears. PRP is less effective for full tears. However, the evidence for PRP’s effectiveness in partial hamstring tendon tears is lacking.
One randomised trial found that PRP combined with rehab produced accelerated recovery compared to rehab alone. However, this study had significant flaws, including a low number of patients.
Another review found no significant difference in return to sport for those who did and did not receive PRP as part of their rehab.
The optimal PRP system for tendons is also hotly debated. Overall, we think a higher concentration of PRP is better.
What are the outcomes of surgery for proximal hamstring tears?
Although the evidence for surgery is based on lower-level studies (i.e. not randomised), the results are generally favourable.
A recent review of all surgical studies on proximal hamstring tears found the following:
- Patient satisfaction was high (above 90%) irrespective of the type of tear (partial vs full thickness or acute vs chronic).
- Better functional recovery was found in partial (75%) compared to complete-thickness tears
- Faster return to sport was found in immediate (4.5 months) compared to delayed surgery (7.3 months)
- Most patients who had a surgical repair returned to their chosen sport (approx 83%).
- Risk of nerve irritation after surgery was lower with immediate (0.7%) compared to delayed surgery (5%)
However, although outcomes are generally good, surgery has significant risks, including infection, re-tear and nerve damage. As always, you should speak to your doctor about balancing the benefits and risks of surgery.
Final word from Sportdoctorlondon about Proximal Hamstring tendon tears
Though relatively uncommon, proximal hamstring tears can be debilitating. Early diagnosis, appropriate treatment, and structured rehab are essential to recovery. While many partial tears can be managed conservatively, complete tears often require surgical repair.
Related contents:
Other Frequently Asked Questions about Proximal Hamstring Tears:
What is the evidence for treating proximal hamstring tendon tears with PRP?
Generally, we use PRP injections for partial tears. PRP is less effective for full tears. However, the evidence for PRP’s effectiveness in partial hamstring tendon tears is lacking.
One randomised trial found that PRP combined with rehab produced accelerated recovery compared to rehab alone. However, this study had significant flaws, including a low number of patients.
Another review found no significant difference in return to sport for those who did and did not receive PRP as part of their rehab.
The optimal PRP system for tendons is also hotly debated. Overall, we think a higher concentration of PRP is better.
What are the outcomes of surgery for proximal hamstring tears?
Although the evidence for surgery is based on lower-level studies (i.e. not randomised), the results are generally favourable.
A recent review of all surgical studies on proximal hamstring tears found the following:
- Patient satisfaction was high (above 90%) irrespective of the type of tear (partial vs full thickness or acute vs chronic).
- Better functional recovery was found in partial (75%) compared to complete-thickness tears
- Faster return to sport was found in immediate (4.5 months) compared to delayed surgery (7.3 months)
- Most patients who had a surgical repair returned to their chosen sport (approx 83%).
- Risk of nerve irritation after surgery was lower with immediate (0.7%) compared to delayed surgery (5%)
However, although outcomes are generally good, surgery has significant risks, including infection, re-tear and nerve damage. As always, you should speak to your doctor about balancing the benefits and risks of surgery.
Final word from Sportdoctorlondon about Proximal Hamstring tendon tears
Though relatively uncommon, proximal hamstring tears can be debilitating. Early diagnosis, appropriate treatment, and structured rehab are essential to recovery. While many partial tears can be managed conservatively, complete tears often require surgical repair.
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