Proximal Hamstring Tear

EpidemiologyProximal Hamstring Tear


Adolescent apophyseal avulsion

- treat non operatively

- unless displaced > 2 cm



- soft tissue avulsion




Usually associated with sporting activities

- skiing

- water skiing


Violent contraction

- knee extended

- hip flexing




Biceps / Semimembranosus / Semitendinosus all attach here





Unble to run


Chronic tears

- may have some neuralgia symptoms




Large haematoma / bruise

Palpable defect

Distal retraction of muscle into thigh with contraction


Proximal Hamstring Rupture Bruise




May see bony avulsion




Proximal Hamstring Avulsion MRI CoronalProximal Hamstring Avulsion MRI Axial


Proximal Hamstring TearProximal Hamstring Tear




Non operative




Harris et al Int J Sports Med 2011

- systematic review

- better subjective outcome / return to sport / hamstring strength with repair c.f. non operative

- better outcomes with acute (< 4 weeks) than chronic repair




Surgical Technique


Patient prone

- knee flexed over sterile gowns



- longitudinal incision centred on ischial tuberosity

- starting at gluteal crease

- allows identification of sciatic nerve distally

- can do a horizontal incision in the gluteal crease if injury very recent, minimal retraction


Superficial dissection

- divide fascia in line with incision

- preserve posterior femoral cutaneous nerve

- identify and elevate inferior edge of gluteus maximus


Deep dissection

- identify and preserve sciatic nerve (lateral to hamstring)


Hamstring Repair Sciatic NerveHamstring Repair Sciatic Nerve 2


Identify proximal hamstring tendon


Proximal Hamstring TendonProximal Hamstring Tendon


Exposure ischial tuberosity

- use osteotomes to create bleeding if needed

- 2 - 3 5 mm metal anchors, double loaded

- whipstich on one side, then use other suture to slide knot


Ischial tuberosityPost suture repair



Proximal Hamstring Rupture Post Op


Post op

- splint with knee flexed

- prevent hip flexion

- crutches


Proximal Hamstring Brace




Residual weakness (60 - 90% other side)



Chronic > 4 weeks



- patient complains they cannot run


More difficult

- careful dissection of sciatic nerve from adhesions

- release hamstring tendon


Augment options

- autologous ITB

- allograft




Release hamstring

- identify nerve, and use vessiloops

- avoid denervating the muscle, must preserve the nerve branches

- identify the ischial tuberosity

- see if hamstring will reach, sometimes will, but cannot repair under tension


Sciatic Nerve ReleaseChronic Hamstring Tear 1Chronic Hamstring Tear 2Chronic Hamstring Tear 3


Prepare allograft

- tendo achilles

- 9 x 20 mm bone block

- drill to 10 x 25 mm tunnel using ACL instruments

- ensure that beath pin does not advance

- secure with 7 x 20 mm screw, bone typically very strong


Drill hole ischial tuberositySecure allograft bone plug with screwSecure allograft bone plug with screw 2


Pulvetaft weave tendon through muscle stump

- through the strongest, thickest part of the stump

- high strength suture tendon to tendon

- can pass again

- tension leg, must be able to reach full extension

- brace for 6 weeks, no sport for 6 months


Hamstring Allograft ReconstructionHamstring Allograft ReconstructionPost Proximal Hamstring Reconstruction




Sarimo et al Am J Sports Med 2008 36

- 41 patients

- 5 chronic requiring achilles allograft

- 96% would have it done again, 80% return to sport

- no difference in strength between acute and chronic


Cohen Am J Sports Med 2012

- 52 patients

- 40 acute, 12 chronic

- 98% satisfied

- minimal difference in outcome between acute and chronic


Murray KSSTA 2009

- achilles allograft recon of chronic (6 months) rupture

- good outcome