Hamstring syndrome - proximal tendinopathy

Hamstring syndrome proximal tendinopathy
Sakari Orava
Prof, MD, PhD
Turku, Finland
1
Gluteal and hamstring anatomy
m. gluteus maximus
2.
m. gluteus medius
3.
m. piriformis
4.
m. gemell. super.
5.
m. obtur. int.
6.
m. gemell. inf.
7.
m. quadr. fem.
8.
mm. semitend./ bic. fem
9.
m. semimembr.
tb trochanter bursa
gb gluteal bursa
ib ischiogluteal bursa
1.
2
Gluteal and hamstring anatomy
3
Anatomy of hamstring muscle
origin
4
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
5
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 by
Freiberg & Winke (1934)
6
Hamstring pains and injuries
1. hamstring syndrome
2. 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”
7
Hamstring syndrome
Symptoms
pain at ischial tuberosity
area
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 posteror
thigh
Clinical signs
palpation pain over ischial
tuberosity
hurdler´s stretch test
(Puranen-Orava test) usually
+
side difference in forewards
bending
straight leg rising often+
(tightness of hamstrings)
neurological status –
atrophy of posterior thigh in
longstanding cases
8
Pathophysiology of hamstring syndrome
= tendinosis (+ sciatic nerve irritation)
stress, small tears,
thickening, tendinosis
semimembranosus
tendon mostly affected
(=fibrous band)
biceps femoris
sometimes, too
9
Diagnosis of hamstring syndrome
running,sitting and car
driving difficult
local pain at hamstring
insertion
MRI +, US +-,ENMG -
10
Radiological diagnosis of hamstring
syndrome (MRI)
11
”Posttraumatic”
hamstring syndrome
after partial tear or
after recurrent
small tears
fibrosis and
tendinosis occurs
to semimembr.- bic.fem
12
Partial hamstring tears –
posttraumatic hamstring syndrome
painful scar
muscle atrophy
poor healing in
active athletes
different types
myotendinous tears
13
Histology of hamstring syndrome
”fibrous band” is a
tendinotic, thickened
semimembranosus
tendon
Fibrosis, tendinosis,
chondroid metaplasia
14
Conservative treatment of
hamstring syndrome
rest from physical
exercise 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 /eccentric
hamstring exercises
pain and NSAID
medication
corticosteroid injections
15
Surgical treatment of hamstring
syndrome
Incisions:
1. Modified Kocher´s
(low ”southern”)
2. Transversal
3. Longitudinal
16
Surgical treatment of hamstring
syndrome
division of semimembr.band, liberation of
sciatic nerve, proximal fasciotomy
17
Surgical treatment of posttraumatic hamstring syndrome
- division of fibrous tendinosis
tendon
- excision of scar clump
- fixation of distal stump to
other tendons or with suture
anchor to bone
- liberation of nerve
18
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 %
19
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
20
Surgery for hamstring syndrome
Tenotomy of semimembr.
tendon 89
Suturation to other
tendons 35
Mitek´s anchor 27
DIAGNOSIS:
Hamstring syndrome 67
Posttraum hamstr sdr 22
21
Results
Excellent
Good
Moderate
Poor
46
31
10
2
Reoperations 6
22
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
23
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
24
Surgical treatment of
hamstring syndrome
in athletes
Lasse Lempainen, Janne Sarimo,
Jouni Heikkilä, Sakari Orava
25