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Anatomy: The hamstring muscle group consists of three muscles:
• Biceps femoris (long and short heads)
• Semitendinosus
• Semimembranosus
These muscles originate from the ischial tuberosity of the pelvis and insert on the posterior aspect of the tibia and fibula. The proximal hamstring tendon complex is formed by the conjoined tendons of these muscles at their origin.
Mechanism of Injury: Proximal hamstring tears typically occur due to:
• Eccentric overload during rapid hip flexion with knee extension
• Forceful hip hyperflexion with knee extension
• Direct blow to the posterior thigh
Common scenarios include:
• Sprinting or sudden acceleration
• Waterskiing
• Slip and fall accidents
Risk Factors:
• Prior hamstring injury
• Inadequate warm-up
• Muscle imbalances
• Fatigue
• Poor flexibility
• Older age
Classification: Proximal hamstring tears are classified based on severity:
• Grade 1: Mild strain with minimal fiber disruption
• Grade 2: Partial tear with significant fiber disruption
• Grade 3: Complete tear or avulsion from the ischial tuberosity
Clinical Presentation: Patients typically present with:
• Sudden onset of posterior thigh pain
• Audible or palpable “pop” at the time of injury
• Difficulty walking or sitting
• Ecchymosis in the posterior thigh
• Palpable defect in severe cases
Diagnosis: 1. History and Physical Examination:
• Mechanism of injury
• Pain localization
• Strength testing
• Range of motion assessment
• Palpation for tenderness and defects
2. Imaging: • MRI: Gold standard for diagnosis
– Evaluates extent of tear
– Identifies tendon retraction
– Assesses muscle quality
• Ultrasound: Useful for dynamic assessment
• X-ray: To rule out avulsion fractures
Treatment: Management depends on the severity of the injury and patient factors:
1. Non-operative Treatment: Indicated for:
• Partial tears with <2 cm retraction
• Older or less active patients
Approach:
• Rest and activity modification • Ice and compression
• NSAIDs for pain management
• Gradual rehabilitation program
2. Surgical Treatment: Indicated for:
• Complete tears
• Partial tears with >2 cm retraction
• Young, active patients
• Athletes
Surgical options:
• Open repair
• Endoscopic repair
Timing:
• Acute repair (within 2-3 weeks) preferred
• Chronic repairs may require tendon grafting
Return to Sport: Criteria for return to sport:
• Full range of motion
• Strength >90% of contralateral side
• Successful completion of sport-specific drills
• Psychological readiness
Typical timeline:
• Non-operative: 3-6 months
• Operative: 6-9 months
Prevention Strategies:
• Proper warm-up and cool-down routines
• Regular stretching and flexibility exercises
• Eccentric hamstring strengthening (e.g., Nordic hamstring curls)
• Core stability training
• Addressing muscle imbalances
• Proper technique in sport-specific movements
Complications:
• Recurrent tears
• Chronic pain
• Sciatic nerve irritation
• Decreased performance
• Heterotopic ossification (post-surgical)
Prognosis: Outcomes depend on various factors:
• Severity of injury
• Time to treatment
• Compliance with rehabilitation
• Age and activity level of patient
Generally:
• Non-operative treatment: 80% return to pre-injury level
• Surgical treatment: 85-95% return to pre-injury level
Long-term Considerations:
• Increased risk of re-injury
• Potential for chronic hamstring tightness
• Need for ongoing maintenance exercises
Proximal hamstring tears represent a significant challenge in sports medicine. Accurate diagnosis, appropriate treatment selection, and comprehensive rehabilitation are essential for optimal outcomes. While surgical intervention is often necessary for complete tears or in high-level athletes, non-operative management can be successful in carefully selected cases. Prevention strategies and long-term maintenance are crucial to minimize the risk of recurrence and ensure sustained athletic performance.
©2025 Dr Frank McCormick All Rights Reserved.
©2025 Dr Frank McCormick All Rights Reserved.
