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1
Hamstring syndrome -
proximal tendinopathy
Sakari Orava Prof, MD, PhD
Turku, Finland
2
Gluteal and hamstring anatomy
1. m. gluteus maximus2. m. gluteus medius3. m. piriformis4. m. gemell. super.5. m. obtur. int.6. m. gemell. inf.7. m. quadr. fem.8. mm. semitend./ bic. fem9. m. semimembr.tb trochanter bursagb gluteal bursaib ischiogluteal bursa
3
Gluteal and hamstring anatomy
4
Anatomy of hamstring muscle
origin
5
Pain syndromes causing hamstring
area pain
� lumbar disc prolapse or protrusion� disc degeneration – internal tear
� spinal stenosis – nerve root canal stenosis
� spondylolysis, -olisthesis� vertebral apophyseal ring fracture
� vertebral anomalies� other radicular and pseudoradicular pains
� neurological diseases
� neuritis of sciatic nerve� neurinoma of sciatic nerve
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Piriformis syndrome
� pain at upper gluteal area� radiation to posterior thigh
and down the leg� postexercise and at night
pain� leg held in semiflexion and
in outward rotation in bed� sitting usually OK, long time
difficult� first reported by Yeman
(1928)� first liberation of sciatic
nerve at gluteal area byFreiberg & Winke (1934)
7
Hamstring pains and injuries
1. hamstring syndrome2. hamstring tears (total, partial)
3. avulsion fracture of ischium
4. apophysitis of ischial bone
5. posterior compartment syndrome of thigh
6. neurological syndromes – ”tight
hamstrings”
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Hamstring syndromeSymptoms Clinical signs
� pain at ischial tuberosityarea
� sitting uncomfortable and painful
� car driving difficult� radiation to posterior thigh,
seldom distally� often recurrent ”hamstring
tears” in history� running with long stride
difficult� exertion pain at ischial
tuberosity and posterorthigh
� palpation pain over ischialtuberosity
� hurdler´s stretch test(Puranen-Orava test) usually+
� side difference in forewardsbending
� straight leg rising often+ (tightness of hamstrings)
� neurological status –� atrophy of posterior thigh in
longstanding cases
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Pathophysiology of hamstring syndrome= tendinosis (+ sciatic nerve irritation)
� stress, small tears, thickening, tendinosis
� semimembranosustendon mostly affected(=fibrous band)
� biceps femorissometimes, too
10
Diagnosis of hamstring syndrome
� running,sitting and cardriving difficult
� local pain at hamstringinsertion
� MRI +, US +-,ENMG -
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Radiological diagnosis of hamstring
syndrome (MRI)
12
”Posttraumatic”
hamstring syndrome
� after partial tear or
after recurrent
small tears
fibrosis and
tendinosis occurs
to semimembr.- bic.fem
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Partial hamstring tears –
posttraumatic hamstring syndrome
� painful scar
� muscle atrophy
� poor healing in active athletes
� different types
� myotendinous tears
14
Histology of hamstring syndrome
� ”fibrous band” is a
tendinotic, thickened
semimembranosus
tendon
� Fibrosis, tendinosis,
chondroid metaplasia
15
Conservative treatment of
hamstring syndrome
� rest from physicalexercise causing pain
� avoid long sitting
� mobility exercises of hip
joint
� muscle strengthing
� local cold, warmth,
physiotherapy
� good warm-up
� massage
� manual treatment
� avoidance of passive and active (over)stretching
� Isometric /eccentrichamstring exercises
� pain and NSAID
medication
� corticosteroid injections
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Surgical treatment of hamstring
syndrome
� Incisions:
1. Modified Kocher´s
(low ”southern”)
2. Transversal
3. Longitudinal
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Surgical treatment of hamstring
syndrome
� division of semimembr.band, liberation of sciatic nerve, proximal fasciotomy
18
Surgical treatment of post-
traumatic hamstring syndrome
- division of fibrous tendinosistendon
- excision of scar clump
- fixation of distal stump to other tendons or with sutureanchor to bone
- liberation of nerve
19
Surgery for hamstring syndrome
MATERIAL
� 89 operations to 81 athletes during 7 years
� 5 x both sides at the same time, 3 x at different
times
� 68 operations to men, 21 to women
� Mean age 33 years (men 32, women 36 years)
� Right side 55 %, left 45 %
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Surgery for hamstring syndrome
MATERIAL� Sports: endurance running 22, soccer 17,
jogging 16, sprinting / hurdling 7, ice hockey 6, weight lifting, gymnastics,orienteering and middle distance running each one athele
� Non-traumatic 62, traumatic 19
� Time from symptoms to surgery 11 months (4 –41 months)
� X-rays 45, MRI 66 pts
21
Surgery for hamstring syndrome
� Tenotomy of semimembr. tendon 89
� Suturation to othertendons 35
� Mitek´s anchor 27
DIAGNOSIS:
� Hamstring syndrome 67
� Posttraum hamstr sdr 22
22
Results
� Excellent 46
� Good 31
� Moderate 10
� Poor 2
� Reoperations 6
23
Postoperative complications of hamstring sdr operations
� postoperative bleeding / hematoma 3
� lesions to posterior cutateous femoral nerve 2
� lesions to muscular branches of sciatic nerve 0
� lesions to perineal nerve branches 1
� postoperative fibrosis 4
� postoperative infection, fistulae 1
� scar problem (keloid, transversal fissuraes) 3
24
Hamstring syndrome in athletes
� hamstring sdr develops usually as overuse sdr
� hamstring injuries/sdr quite common in athletes
and usually heal well – posttraumatic hamstring
sdr may occur
� right diagnosis often difficult
� decision and timing of surgery difficult
� possible to treat surgically with good result
25
Surgical treatment of
hamstring syndrome
in athletes
Lasse Lempainen, Janne Sarimo, Jouni Heikkilä, Sakari Orava