Traumatic Hamstring Rupture - an uncommon running injury
BY JANET HAMILTON, MA RCEP, CSCS
For years I’ve taught that the majority of running injuries are overuse injuries. They usually present themselves gradually with subtle symptoms at first. Overlooking the severity of an injury and “pushing through” usually doesn’t work out so well. Misinterpreting the severity of an injury is even worse. If the athlete pays attention early on and addresses the issue quickly, the time off of running is usually brief.
We seldom have a need to discuss another type of injury – the traumatic type.
This topic is deeply personal. As a coach I’ve always been focused on my athletes and rarely discuss my personal running life. But I recently learned a valuable – and very painful lesson about the importance of paying attention to our body’s responses to any given training bout and striving to provide it with what it needs to repair and strengthen and improve. And I hope that it can help you.
While out on a run in late January, I fell while trying to avoid being hit by an oncoming vehicle. I knew instantly that I had severely strained my right hamstring. It took one hour to walk a half-mile home. And it was excruciating.
I knew from clinical experience that this was bad, but also that it could have been worse. Once I got home, I got some crutches and followed a strict protocol of rest, ice, compression, elevation and protection. I knew enough not to try to “stretch it out” or go after it with a foam roller. Since I still had function (albeit painful) in the hamstring muscle, I was confident it wasn’t a full rupture.
Within 48 hours bruising appeared on the back of my leg and I started some gentle active motion to carefully encourage the healing process. I was careful to avoid anything that was painful. I was confident I was doing everything that could be done at the time. I improved slowly and steadily over the next 8 days. By the time I went in for an MRI on day 10, I was back to slowly walking without the crutches.
The results of the MRI came as a shock. Instead of a partial tear the radiologist reported a full-thickness tear/avulsion of one of the 3 muscles that makes up the hamstring group. (Avulsion means the tendon has torn free of its bony attachment). The MRI reported that my Semimembranosus – one of the hamstring muscles that spans from the pelvis above to the to the tibia below – was torn and that the tendon had now retracted about 2cm away from where it used to attach to the bone in my pelvis. Ouch.
I went into research mode in advance of the visit with the orthopedic surgeons, scouring peer-reviewed clinical journals for information. I knew I wanted two opinions. What were my options? What are the possible outcomes? How does one decide if the injury is severe enough to warrant surgery? I took those questions and more with me into the surgeon’s office. (I’ve put some tips here on how to communicate with your medical professionals). What I learned from the research and the orthopedists about this injury surprised me.
- Though hamstring strains are common, full rupture is a fairly uncommon injury. Many orthopedists may only perform 1 or 2 hamstring repair surgeries in a year. The most common cause of injury is a fall while waterskiing, but apparently bull-riders and Australian footballers are also prone. In my case, the injury was caused by my forward falling momentum over my right leg.
- It’s an injury whose severity is sometimes missed early on. Because the athlete will have gradual improvement in symptoms and function (like I did) and assume that they are not as injured as they really are, they may delay seeking care.
- Delays may make the outcome worse. Delayed repair due to misinterpreting the magnitude of the injury is associated with increased risk of scarring around the sciatic nerve and a worse outcome from surgery. The best outcomes from surgical reattachment of the tendon (or tendons) seem to be had when it is performed within the first 2- 3 weeks .
- The MRI can be difficult to interpret. According to the orthopedic surgeon who performed my surgery (he does about 15 a year), the MRI interpretation may under represent the severity of the injury. In his experience, when an MRI reports one of the hamstrings as a “full thickness tear/avlusion” there’s often damage to more than one.
Such was the case in my injury. Rather than the one tendon torn off the bone, he found that the tendon that provides a shared attachment for the other two hamstring muscles was also torn, with over 80% of it no longer attached to the bone. This was NOT picked up by the radiologist on the MRI.
So what is the point of all of this? Basically it is to encourage a higher level of suspicion when an athlete reports to you that they fell and “pulled” their hamstring muscle. Ask more questions. If they have a history of hamstring “tendonitis” in the past (which may leave the tendon in a weakened condition) – have an even higher level of suspicion. In my case, had I not insisted on an MRI I would have likely continued my course of conservative rehabilitation exercises and attempted to return to running a few weeks or months down the road only to find out the weakness in my leg impaired my running. At that point surgical repair might not have been a viable option.
When an athlete reports a fall and subsequent hamstring strain, with associated bruising – encouraging them to see an orthopedist and get some diagnostic imaging early on seems like a sensible plan to me. Had I done that myself and not waited 10 days… I’d be 10 days closer to getting back on my feet. Just sayin’….
Be safe my friends.
click the link to see previous published coach's tips
For more reading on this topic:
Surgical repair of complete proximal hamstring tendon ruptures in water skiers and bull riders: a report of four cases and review of the literature. Chakravarthy J1, Ramisetty N, Pimpalnerkar A, Mohtadi N. Br J Sports Med. 2005 Aug;39(8):569-72.
Functional Outcomes and Return to Sports After Acute Repair, Chronic Repair, and Allograft Reconstruction for Proximal Hamstring Ruptures.
Rust DA, Giveans MR, Stone RM, Samuelson KM, Larson CM. Am J Sports Med. 2014 Apr 3;42(6):1377-1383
DIAGNOSIS AND EXPEDITED SURGICAL INTERVENTION OF A COMPLETE HAMSTRING AVULSION IN A MILITARY COMBATIVES ATHLETE: A CASE REPORT
Shaun J. O'Laughlin, PT, DPT, OCS, Timothy W. Flynn, PT, PhD, Richard B. Westrick, PT, DSc, and Michael D. Ross, PT, DHSc Int J Sports Phys Ther. 2014 May; 9(3): 371–376. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4060315/
Proximal hamstring avulsion injuries: a technique note on surgical repairs. Pombo M1, Bradley JP. Sports Health. 2009 May;1(3):261-4. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3445245/
RECURRENT HAMSTRING INJURY: CONSIDERATION FOLLOWING OPERATIVE AND NON‐OPERATIVE MANAGEMENT
John DeWitt, PT, DPT, SCS, ATC and Tim Vidale, PT, DPT Int J Sports Phys Ther. 2014 Nov; 9(6): 798–812. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4223289/