Abstract
Purpose
The purpose of this study was to assess the post-operative return to sport and re-injury rates following surgical repair of acute, first-time, high-grade intramuscular hamstring tendon injuries in high level athletes.
Methods
Patients were identified using the databases of two sports surgeons. Once patients were identified their clinical notes and imaging were reviewed to confirm that all patients had injuries to the intramuscular portion of the distal aspect of the proximal biceps femoris tendon. All imaging was reviewed by an experienced musculoskeletal radiologist to confirm diagnosis. Surgery for such injuries was indicated in high-level athletes presenting with acute hamstring injuries. All patients were operated on within 4 weeks. Outcomes included Tegner scores, return to sport, Lower Extremity Functional Score (LEFS), current hamstring symptoms and complications including re-injury.
Results
Eleven injuries (10 patients) were included in the study. All patients were male and Australian Rules Football players. Six patients were professional athletes and 4 semi-professional athletes. Median age was 24.5 (range 21–29) and median follow-up period was 33.7 months (range; 16–65). 91% were British Athletic Muscle Injury Classification (BAMIC) 3c and 9% were BAMIC 4c. 91% were classed as MR2 and 9% as MR3 on the simplified four-grade injury classification. Athletes achieved return to play (RTP) at an average of 3.1 months (SD 1.0) post repair. All but one patient achieved a Tegner score equal to pre-injury levels. Maximum LEFS was achieved by all patients. Minor pain scores (all with VAS < 1/10) on sciatic and functional stretch were recorded in 36% and 27% of patients respectively, with subtle neural symptoms (9%) and subjective tightness (36%) also noted. There were no surgical complications in our patient cohort. No patients had a re-injury or re-operation.
Conclusions
Surgical repair of high-grade intramuscular tendon injuries of the biceps femoris hamstring muscle in athletes resulted in high levels of return to pre-injury sporting levels and no re-injuries. The intra-muscular tendon should be scrutinized when assessing hamstring injuries in elite sport and offer surgery in high-grade cases.
Level of evidence
IV.
Similar content being viewed by others
References
Ekstrand J, Healy JC, Waldén M, Lee JC, English B, Hägglund M (2012) Hamstring muscle injuries in professional football: the correlation of MRI findings with return to play. Br J Sports Med 46:112–117
Ekstrand J, Krutsch W, Spreco A, Van Zoest W, Roberts C, Meyer T, Bengtsson H (2020) Time before return to play for the most common injuries in professional football: a 16-year follow-up of the UEFA elite Club injury study. Br J Sports Med 54:421–426
Orchard JW, Seward H, Orchard JJ (2013) Results of 2 decades of injury surveillance and public release of data in the Australian Football League. Am J Sports Med 41:734–741
Pollock N, Patel A, Chakraverty J, Suokas A, James SL, Chakraverty R (2016) Time to return to full training is delayed and recurrence rate is higher in intratendinous (‘c’) acute hamstring injury in elite track and field athletes: clinical application of the British Athletics Muscle Injury Classification. Br J Sports Med 50:305–310
Raya-González J, de Ste CM, Read P, Castillo D (2020) A Longitudinal Investigation of muscle injuries in an elite spanish male academy soccer club: a hamstring injuries approach. Appl Sci 10:1610. https://doi.org/10.3390/app10051610
McAuley S, Dobbin N, Morgan C, Goodwin PC (2021) Predictors of time to return to play and re-injury following hamstring injury with and without intramuscular tendon involvement in adult professional footballers: a retrospective cohort study. J Sci Med Sport 25:216–221
Shamji R, James SL, Botchu R, Khurniawan KA, Bhogal G, Rushton A (2021) Association of the British athletic muscle injury classification and anatomic location with return to full training and reinjury following hamstring injury in elite football. BMJ Open Sport Exerc Med. 7:e001010. https://doi.org/10.1136/bmjsem-2020-001010
Brooks JH, Fuller CW, Kemp SP, Reddin DB (2006) Incidence, risk, and prevention of hamstring muscle injuries in professional rugby union. Am J Sports Med 34:1297–1306
Heiderscheit BC, Sherry MA, Silder A, Chumanov ES, Thelen DG (2010) Hamstring strain injuries: recommendations for diagnosis, rehabilitation, and injury prevention. J Orthop Sports Phys Ther 40:67–81
Koulouris G, Connell DA, Brukner P, Schneider-Kolsky M (2007) Magnetic resonance imaging parameters for assessing risk of recurrent hamstring injuries in elite athletes. Am J Sports Med 35:1500–1506
Orchard J, Best TM (2002) The management of muscle strain injuries: an early return versus the risk of recurrence. Clin J Sport Med 12:3–5
Verrall GM, Slavotinek JP, Barnes PG, Fon GT, Spriggins AJ (2001) Clinical risk factors for hamstring muscle strain injury: a prospective study with correlation of injury by magnetic resonance imaging. Br J Sports Med 35:435–439
Woods C, Hawkins RD, Maltby S, Hulse M, Thomas A, Hodson A (2004) Football Association Medical Research Programme. The Football Association Medical Research Programme: an audit of injuries in professional football—analysis of hamstring injuries. Br J Sports Med 38:36–41
Erickson LN, Sherry MA (2017) Rehabilitation and return to sport after hamstring strain injury. J Sport Health Sci 6:262–270
De Smet AA, Best TM (2000) MR imaging of the distribution and location of acute hamstring injuries in athletes. Am J Roentgenol 174:393–399
Garrett WE Jr (1996) Muscle strain injuries. Am J Sports Med 24:S2–S8
Brukner P (2015) Hamstring injuries: prevention and treatment—an update. Br J Sports Med 49:1241–1244
Brukner P, Connell D (2016) ‘Serious thigh muscle strains’: beware the intramuscular tendon which plays an important role in difficult hamstring and quadriceps muscle strains. Br J Sports Med 50:205–208
Arner JW, McClincy MP, Bradley JP (2019) Hamstring injuries in athletes: evidence-based treatment. JAAOS 27:868–877
Bodendorfer BM, Curley AJ, Kotler JA, Ryan JM, Jejurikar NS, Kumar A, Postma WF (2018) Outcomes after operative and nonoperative treatment of proximal hamstring avulsions: a systematic review and meta-analysis. Am J Sports Med 46:2798–2808
Shambaugh BC, Olsen JR, Lacerte E, Kellum E, Miller SL (2017) A comparison of nonoperative and operative treatment of complete proximal hamstring ruptures. Orthop J Sports Med 5:2325967117738551
Patel A, Chakraverty J, Pollock N, Chakraverty R, Suokas AK, James SL (2015) British athletics muscle injury classification: a reliability study for a new grading system. Clin Radiol 70:1414–1420
Koulouris G, Connell D (2005) Hamstring muscle complex: an imaging review. Radiographics 25:571–586
Brukner P, Cook JL, Purdam CR (2018) Does the intramuscular tendon act like a free tendon? Br J Sports Med 52:1227–1228
Garrett WE Jr, Rich FR, Nikolaou PK, Vogler JB 3rd (1989) Computed tomography of hamstring muscle strains. Med Sci Sports Exerc 21:506–514
Crema MD, Jarraya M, Engebretsen L, Roemer FW, Hayashi D, Domingues R, Skaf AY, Guermazi A (2018) Imaging-detected acute muscle injuries in athletes participating in the Rio de Janeiro 2016 Summer Olympic Games. Br J Sports Med 52:460–464
Comin J, Malliaras P, Baquie P, Barbour T, Connell D (2013) Return to competitive play after hamstring injuries involving disruption of the central tendon. Am J Sports Med 1:111–115
Crema MD, Guermazi A, Reurink G, Roemer FW, Maas M, Weir A, Moen MH, Goudswaard GJ, Tol JL (2017) Can a clinical examination demonstrate intramuscular tendon involvement in acute hamstring injuries? Orthop J Sports Med 5:2325967117733434
Askling CM, Tengvar M, Saartok T, Thorstensson A (2007) Acute first-time hamstring strains during high-speed running: a longitudinal study including clinical and magnetic resonance imaging findings. Am J Sports Med 35:197–206
Fournier-Farley C, Lamontagne M, Gendron P, Gagnon DH (2016) Determinants of return to play after the nonoperative management of hamstring injuries in athletes: a systematic review. Am J Sports Med 44:2166–2172
van der Made AD, Almusa E, Whiteley R, Hamilton B, Eirale C, van Hellemondt F, Tol JL (2018) Intramuscular tendon involvement on MRI has limited value for predicting time to return to play following acute hamstring injury. Br J Sports Med 52:83–88
Van Der Made AD, Almusa E, Reurink G, Whiteley R, Weir A, Hamilton B, Maas M, Ngai AS, Moen MH, Goudswaard GJ (2018) Intramuscular tendon injury is not associated with an increased hamstring reinjury rate within 12 months after return to play. Br J Sports Med 52:1261–1266
Hallén A, Ekstrand J (2014) Return to play following muscle injuries in professional footballers. J Sports Sci 32:1229–1236
Macdonald B, McAleer S, Kelly S, Chakraverty R, Johnston M, Pollock N (2019) Hamstring rehabilitation in elite track and field athletes: applying the British athletics muscle injury classification in clinical practice. Br J Sports Med 53:1464–1473
Pollock N, James SL, Lee JC, Chakraverty R (2014) British athletics muscle injury classification: a new grading system. Br J Sports Med 48:1347–1351
Eggleston L, McMeniman M, Engstrom C (2020) High-grade intramuscular tendon disruption in acute hamstring injury and return to play in Australian Football players. Scand J Med Sci Sports 30:1073–1082
Pollock N, Kelly S, Lee J, Stone B, Giakoumis M, Polglass G, Brown J, MacDonald B (2022) A 4-year study of hamstring injury outcomes in elite track and field using the British Athletics rehabilitation approach. Br J Sports Med 56:257–263
Blakeney WG, Zilko SR, Edmonston SJ, Schupp NE, Annear PT (2017) A prospective evaluation of proximal hamstring tendon avulsions: improved functional outcomes following surgical repair. Knee Surg Sports Traumatol Arthrosc 25:1943–1950
Chang JS, Kayani B, Plastow R, Singh S, Magan A, Haddad FS (2020) Management of hamstring injuries: current concepts review. Bone Joint J 102:1281–1288
Knapik DM, Metcalf KB, Voos JE (2018) Isolated tearing and avulsion of the distal biceps femoris tendon during sporting activities: a systematic review. Orthop J Sports Med 6:2325967118781828
Thompson JW, Plastow R, Kayani B, Moriarty P, Asokan A, Haddad FS (2021) Surgical repair of distal biceps femoris avulsion injuries in professional athletes. Orthop J Sports Med 9:2325967121999643
Lempainen L, Kosola J, Pruna R, Puigdellivol J, Sarimo J, Niemi P, Orava S (2018) Central tendon injuries of hamstring muscles: case series of operative treatment. Orthop J Sports Med 6:2325967118755992
van Heumen M, Tol JL, de Vos R-J, Moen MH, Weir A, Orchard J, Reurink G (2017) The prognostic value of MRI in determining reinjury risk following acute hamstring injury: a systematic review. Br J Sports Med 51:1355–1363
Vermeulen R, Almusa E, Buckens S, Six W, Whiteley R, Reurink G, Weir A, Moen M, Kerkhoffs GM, Tol JL (2021) Complete resolution of a hamstring intramuscular tendon injury on MRI is not necessary for a clinically successful return to play. Br J Sports Med 55:397–402
Turl SE, George KP (1998) Adverse neural tension: a factor in repetitive hamstring strain? J Orthop Sports Phys Ther 27:16–21
Funding
Nil to declare.
Author information
Authors and Affiliations
Contributions
RSA, SC: data analysis; manuscript writing, manuscript review. EK: data analysis; manuscript review. PD’A, PA: inception, manuscript review.
Corresponding author
Ethics declarations
Conflict of interest
Each author certifies that he or she has no commercial associations (e.g., consultancies, stock ownership, equity interest, patent/licensing arrangements, etc.) that might pose a conflict of interest in connection with the submitted article.
Ethical approval
Ethical approval was obtained via local ethics committee/process at the University of Western Australia (2021/ET000117).
Additional information
Publisher's Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Rights and permissions
Springer Nature or its licensor (e.g. a society or other partner) holds exclusive rights to this article under a publishing agreement with the author(s) or other rightsholder(s); author self-archiving of the accepted manuscript version of this article is solely governed by the terms of such publishing agreement and applicable law.
About this article
Cite this article
Aujla, R.S., Cecchi, S., Koh, E. et al. Surgical treatment of high-grade acute intramuscular hamstring tendon injuries in athletes leads to predictable return to sports and no re-injuries. Knee Surg Sports Traumatol Arthrosc 31, 4601–4606 (2023). https://doi.org/10.1007/s00167-023-07477-x
Received:
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s00167-023-07477-x