M u s c u l o s k e l e t a l I m a g i n g • C l i n i c a l Pe r s p e c t i ve

Zissen et al.
Imaging of High Hamstring Tendinopathy

Musculoskeletal Imaging
Clinical Perspective

High Hamstring Tendinopathy:

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MRI and Ultrasound Imaging

and Therapeutic Efficacy of
Percutaneous Corticosteroid
Injection
Maurice H. Zissen1 OBJECTIVE. The goals of this study were to review the MRI and sonographic findings in
Grant Wallace1 patients diagnosed clinically with high hamstring tendinopathy and to evaluate the efficacy of
Kathryn J. Stevens1 ultrasound-guided corticosteroid injections in providing symptomatic relief.
Michael Fredericson2 CONCLUSION. MRI is more sensitive than ultrasound in detecting peritendinous ede-
Christopher F. Beaulieu1 ma and tendinopathy at the proximal hamstring origin. Fifty percent of patients had symp-
tomatic improvement lasting longer than 1 month after percutaneous corticosteroid injection,
Zissen MH, Wallace G, Stevens KJ, Fredericson and 24% of patients had symptom relief for more than 6 months.
M, Beaulieu CF

Keywords: corticosteroid, hamstring, MRI, percutaneous
injection, tendinopathy, ultrasound
DOI:10.2214/AJR.09.3674
Received September 23, 2009; accepted after revision
March 17, 2010.
1
Department of Radiology, Stanford University School
of Medicine, 300 Pasteur Dr., Stanford, CA 94305-5105.
Address correspondence to C. F. Beaulieu
(beaulieu@stanford.edu).
2
Department of Orthopedic Surgery, Stanford University
School of Medicine, Sports Medicine Center, Redwood
City, CA.
AJR 2010; 195:993–998
0361–803X/10/1954–993
© American Roentgen Ray Society
A
cute strains of the mid and distal
hamstring myotendinous com-
plex are common athletic inju-
ries [1–5]. Proximal hamstring
tendon pathologic abnormalities, including
tendon degeneration, partial tearing, and
peritendinous inflammatory reaction, are
less common [6]. These abnormalities are
grouped clinically as “high hamstring tendi-
nopathy,” and patients usually present with
subacute onset of deep buttock or thigh pain
that is exacerbated by repetitive activity, such
as long-distance running, and often is aggra-
vated by sitting. In many of these patients,
conservative management is ineffective, and
MRI is performed to confirm the diagnosis,
to grade the extent of injury, or to search for
alternative explanations. In cases where MRI
establishes an abnormality at the hamstring
origin, or where MRI findings are normal
but clinical suspicion is high, we have per-
formed ultrasound-guided injections of cor-
ticosteroids and local anesthetic at the ham-
string origin.
The goals of this article are to review our
institution’s experience with MRI and ultra-
sound imaging of the proximal hamstring
tendons and to establish the efficacy of ultra-
sound-guided corticosteroid injection as an
integral part of overall patient management.
Materials and Methods
Patient Selection Criteria
This retrospective study was performed in com-
pliance with HIPAA regulations and with approval
from our institutional review board. We performed
a computerized search of medical records and im-
aging reports at our institution, searching for the
terms “hamstring,” “MRI,” “ultrasound,” and
“corticosteroid injection.” Patients undergoing im-
aging and injection of hamstring disorders in the
mid or distal thigh or about the knee were exclud-
ed. This search identified 65 patients who received
ultrasound-guided proximal hamstring injections
between January 2002 and December 2008. There
were 28 men (43.1%) and 37 women (56.9%) with
a mean age of 37.4 years (range, 19–65 years). For
35 patients, MRI was performed at our facility and
images were available to review. All patients had
ultrasound images available for review.
Image Review
Two authors reviewed the MRI and ultrasound
studies for all patients. MR studies included small
field-of-view (~24–28 cm) T1- and T2-weight-
ed fat-suppressed images in three planes using a
phased-array coil at 1.5 T. MR images were re-
viewed for findings of peritendinous fluid or ede-
ma (peritendinitis), tendinopathy, partial tear, and
bone marrow edema in the ischial tuberosity. Ul-
trasound images were reviewed for peritendinous
fluid or edema, hypoechoic areas or thickening
of the tendons consistent with tendinopathy, and
echogenic foci consistent with calcifications. The
mean (± SD) time between the MR and ultrasound
studies was 90 ± 16 days (range, 0–171 days).
Ultrasound-Guided Peritendinous Injection
All injections were performed by an experienced
musculoskeletal radiologist after obtaining written
informed consent. Patients were asked to identi-
fy, if possible, the site of maximum pain, either by

AJR:195, October 2010 993

 Zissen et al.

palpation or by performing resistance maneuvers.
With the patient in the prone position, a 6- to 10-
MHz linear transducer was used to localize the
ischial tuberosity and proximal hamstring tendons
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TABLE 1: Imaging Findings of Patients Receiving Ultrasound-Guided
Corticosteroid–Anesthetic Injection
Characteristic No. (%) of Patients
Ultrasound findings (n = 65 patients)

in both transverse and sagittal planes. Color Dop-

pler was used to identify and avoid visible vascular
structures. Scanning laterally to the hamstring ori-
gin in the sagittal plane, the sciatic nerve was simi-
larly identified, and injections were performed me-
dially to this structure. A freehand technique was
used in the sagittal plane to guide the injection, first
using 1% lidocaine with a 1.5-inch-long 21-gauge
needle. If this needle was sufficiently long to reach
the hamstring tendons, the therapeutic mixture was
injected through the same needle. In larger patients,
a 3-inch-long 20-gauge spinal needle was inserted
after removal of the 1.5-inch needle.
Two therapeutic mixtures were used in this
study. The first consisted of 1 mL of triamcino-
lone acetonide 40 (40 mg/mL) plus 5 mL of bupi-
vacaine. The second consisted of 1 mL of triam-
cinolone acetonide 40 (40 mg/mL) with 0.5 mL of
dexamethasone sodium phosphate (4 mg/mL) and
5 mL of bupivacaine. The therapeutic mixture was
administered using a 21- or 20-gauge needle un-
der sterile conditions as described in the previous
paragraph. After needle placement, the therapeu-
tic mixture was injected immediately superficial
to the hamstring tendons, and real-time sonog-
raphy was used to monitor tracking of the fluid
along the peritendinous tissues in both the sagittal
and transverse directions. Repositioning was per-
formed if fluid was not tracking over a length of
tendon at least 5 cm long, to spread the medica-
tion. After injection and needle removal, the per-
itendinous soft tissues were massaged gently for
1–2 minutes to further spread the medication in
the tissue planes. With direct ultrasound visual-
ization of the needle, we avoided intratendinous
injection. Note also that, to avoid intratendinous
injection, we did not attempt to inject deeper at the
tendon–bone interface. On completion of the pro-
cedure, patients were asked to assess pain relief in
the immediate postinjection period.
Peritendinitis (fluid or edema)
Tendinopathy
Calcifications
Normal
MRI findings (n = 35 patients)
Peritendinitis (fluid or edema)
Tendinopathy
Bone marrow edema
Partial tear
Normal
subjective pain assessment questions that includ-
ed the degree of pain relief as well as duration of
symptom resolution. The patients were also asked
questions related to the mechanism of injury, prior
activity level, prior treatment techniques (includ-
ing medical management and physical therapy),
and any complications experienced as a result of
the procedure.
Statistical Analysis
We defined patients with “significant improve-
ment” of symptoms as those who reported dura-
tion of symptomatic improvement longer than 1
month and patients with “insignificant improve-
ment” as those who reported having less than 1
month of symptomatic resolution. We then used a
Fisher’s exact test to determine whether length of
symptoms before injection, presence of tendinop-
athy on MRI or ultrasound, presence of peritendi-
nitis on MRI or ultrasound or absence of imaging
13 (20)
11 (16.9)
3 (4.6)
40 (61.5)
22 (62.9)
9 (25.7)
7 (20)
7 (20)
8 (22.9)
findings on either MRI or ultrasound were statisti-
cally associated with improved outcomes.
Results
Imaging Results
The imaging findings observed on retro-
spective review of 65 ultrasound studies and
35 MRI studies are shown in Table 1. For ul-
trasound, 40 (61.5%) of 65 patients showed
normal tendon thickness and echogenici-
ty without surrounding fluid or tendon cal-
cifications. MRI findings were normal for
eight (22.9%) of 35 patients. On both ultra-
sound (20%) and MRI (62.9%), peritendini-
tis, manifesting as fluid or edema adjacent to
the proximal hamstring origin, was the most
common abnormal imaging finding. This is
illustrated in Figure 1. Findings consistent
with tendinopathy were shown by ultrasound
in 16.9% and by MRI in 25.7% of patients, as

Telephone Questionnaire
Review of clinical records showed that only a
small number of patients returned to the referring
physician for a follow-up visit; thus, no useful data
were available regarding efficacy of the injections
from this resource. We constructed a question-
naire and attempted to contact by telephone all 65
patients who received the ultrasound-guided per-
itendinous injection. A total of 38 patients were
reached and agreed to participate in the study. Fig. 1—20-year-old woman with proximal hamstring peritendinitis.
The mean time to follow-up was 4 years (range, A, Axial T2-weighted fat-suppressed image shows increased T2 signal intensity surrounding hamstring
tendons at their origin (arrowhead), suggestive of peritendinitis.
6 months to 8 years). Verbal informed consent B, Corresponding sagittal ultrasound image shows peritendinous fluid collection (arrows) superficial to
was obtained before asking the patients a series of hamstring tendon (t) at its origin at ischial tuberosity (it).

994 AJR:195, October 2010

 Imaging of High Hamstring Tendinopathy

pain relief after injection, 11 patients who re-

sponded had complete resolution of symp-
toms, eight had moderate resolution, and 10
had mild resolution. Nine patients experi-
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enced no pain relief either immediately or lat-

Fig. 2—55-year-old woman with proximal hamstring tendinopathy.
A, Axial T2-weighted fat-suppressed image reveals increased T2 signal within tendon origin (arrowhead),
consistent with tendinopathy.
B, Corresponding ultrasound image shows hypoechogenicity and heterogeneity (arrows) of hamstring tendon
(t) at its origin at ischial tuberosity (it).
shown in Figure 2. Ultrasound is incapable
of detecting bone marrow edema, and no dis-
crete partial tears were evident on ultrasound
on retrospective image review. MRI showed
bone marrow edema and small (< 5 mm) foci
of near fluid signal, suggesting partial tear-
ing at the proximal hamstring tendon origin
in 20% of the studies (Fig. 3). As indicated
above, patients with MR findings consistent
with discrete partial tears involving the ma-
jority of the cross-section of one of the ham-
string components or greater were not be-
lieved appropriate for percutaneous steroid
injection. As shown in Figure 4, ultrasound
was capable of depicting echogenic intraten-
dinous foci consistent with calcifications in
4.6% of patients.
The technique of percutaneous injection
is described in Materials and Methods. Fig-
ure 5 shows a frame from the real-time ultra-
sound images during a typical injection.
Clinical Outcomes
A total of 65 injections were performed,
with a mean time to follow-up of 4 years
(range, 6 months to 8 years). A total of 38
of the original 65 patients responded to our
survey (Table 2). In terms of the degree of
er after the injection. The duration of symp-
tom resolution was longer than 6 months for
nine (23.7%) of the 38 patients, 1–6 months
for 10 patients (26.3%), 1 week to 1 month
for 9 patients (23.7%), and less than 1 week
for one patient (2.6%). The same nine pa-
tients who did not experience any pain relief
immediately after the injection also felt no
later benefit of the injection.
In addition to assessment of symptomatic
relief from corticosteroid injection, we sur-
veyed study patients regarding other treat-
ment techniques. We found that that 26
(68.4%) of 38 patients had taken oral non-
steroidal antiinflammatory medications be-
fore the ultrasound-guided peritendinous in-
jection. The remaining 12 patients (31.6%)
took no prior medication, whereas one had a
previous steroid injection without ultrasound
guidance. The majority of patients (30/38
[79%]) had undergone physical therapy be-
fore the injection.
In terms of the ultimate outcome, 27
(71.0%) of 38 patients reported returning to
their presymptom level of activity after the
injection, and three of these individuals ac-
tually described a higher level of activity.
At the time of follow-up questioning, seven
of the patients (18.4%) had not been able to

Fig. 3—45-year-old man with proximal hamstring
injury and bone marrow edema. Axial T2-weighted
fat-suppressed image shows bone marrow edema
(arrows) within ischial tuberosity adjacent to
hamstring tendon origin. There is also partial
undersurface irregularity of adjacent hamstring
tendons.
Fig. 4—32-year-old man with hamstring injury.
Sagittal ultrasound image shows small focus of
hyperechogenicity consistent with calcification
(arrow). it = ischial tuberosity.
Fig. 5—28-year-old man with proximal hamstring
tendinopathy. Sagittal ultrasound image shows
22-gauge needle in place (arrowheads) for
sonography-guided injection. Tip is immediately
adjacent to superficial surface of hamstring tendon
(t). it = ischial tuberosity.

AJR:195, October 2010 995


TABLE 2: Clinical Outcomes for 38 of 65 Patients Receiving Ultrasound-
Guided Corticosteroid–Anesthetic Injection
Characteristic
Duration of symptoms before injection
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<6m
6 m to 1 y
>1y
Degree of symptom resolution
No resolution
Mild resolution
Moderate resolution
Complete resolution
Duration of symptom resolution
No resolution
< 1 wk
1 wk to 1 m
1–6 m
>6m
TABLE 3: Duration of Symptoms and Imaging Characteristics Associated
With Significant Symptomatic Improvement
Characteristic
Duration of symptoms < 1 y
Normal MRI finding
Normal ultrasound finding
Presence of tendinopathy on MRI or ultrasound
Presence of peritendinitis on MRI or ultrasound
aFisher’s exact test.
return to the level of activity they enjoyed
before the onset of symptoms. None of the
contacted patients experienced significant
complications due to the injection.
To assess for imaging features that might
be predictive of a positive response to steroid
injections, we tested for associations between
each of the imaging features in Table 2 and
the clinical outcome we defined as significant
improvement. The duration of symptoms be-
fore injection, the absence of MRI findings,
and the presence of tendinopathy or periten-
dinitis on either technique were not statisti-
cally predictive of response to therapy (Table
3). There was, however, a statistically signifi-
cant association between the absence of find-
ings on ultrasound and a significant clinical
response to therapy with a p value of 0.02.
Discussion
Proximal hamstring tendinopathy is in-
creasingly being recognized as an important
cause for chronic pain in the active popula-
996 AJR:195, October 2010
Zissen et al.
No. (%) of Patients
8 (21)
15 (39.5)
15 (39.5)
9 (23.7)
10 (26.3)
8 (21)
11 (28.9)
9 (23.7)
1 (2.6)
9 (23.7)
10 (26.3)
9 (23.7)
pa
0.5
0.39
0.02
0.55
0.14
tion [7, 8]. This injury is distinct from the
more common type of acute muscle strain
that is typically limited to the myotendi-
nous junction of the biceps femoris muscle
and is routinely managed clinically with the
protocol of rest, ice, compression, and eleva-
tion as the preferred first-line approach [1,
4]. For proximal hamstring tendinopathy,
treatments such as antiinflammatory medi-
cations for pain control as well as rehabili-
tation programs involving soft-tissue mobi-
lization, frequent stretching, and progressive
strengthening can help the hamstring mus-
cles regain flexibility and are frequently used
in attempts to prevent further injury or rein-
jury [2, 5]. For the majority of conservative-
ly managed patients, the time to full recov-
ery is typically 2–6 months. However, in up
to 20% of patients, symptoms can persist for
more than 6 months and become recalcitrant
to conservative treatment [9, 10]. With more
frequent use of ultrasound and MRI in these
patients, we are increasingly able to diagnose
the source of the pain and focus our treat-
ments specifically to the injured muscle.
Adler et al. [11, 12] have described an ef-
fective method of ultrasound-guided anes-
thetic–corticosteroid injections into the ad-
jacent bursa of the iliopsoas tendon that is
useful in diagnosing and treating exercise-
related iliopsoas pathology. Although peri-
tendinous hamstring injections have been re-
ported by other groups in limited numbers,
the efficacy of this technique has not been
evaluated. This work represents our institu-
tion’s substantial experience with imaging
of the hamstring origin and sonographical-
ly guided percutaneous treatments in the set-
ting of a clinical diagnosis of high hamstring
tendinopathy. Areas of proximal hamstring
tendinopathy were identified by locating the
thickened and hypoechoic areas of tendon on
sonography, allowing us to target our thera-
py to this location under direct visualization.
Ultrasound is a low-cost nonionizing readi-
ly available technique for the evaluation of
tendons, muscles, cysts, and other fluid col-
lections. Ultrasound guidance for soft-tissue
injections has been found to be an excellent
tool for needle localization because of the
real-time imaging and excellent resolution of
desired structures [13–16].
In the setting of tendinopathy, it is hypoth-
esized that the use of corticosteroids is ben-
eficial by limiting the chronic inflammation
that may lead to tendon scarring and adhe-
sion formation [17–19]. Although there is
concern that the introduction of corticoster-
oids to a site of injury could limit healing and
subsequently weaken the underlying tendon,
leading to future degeneration and rupture,
there is no reliable documentation of the del-
eterious effects of peritendinous injections
[7, 20]. It has also been suggested by multi-
ple groups that the major benefit of perform-
ing these injections with ultrasound guidance
is the accurate placement of the injection into
the tendon sheath, avoiding the tendon itself
and thereby minimizing adverse events [11,
16]. The immediate improvement of symp-
toms resulting from the injected anesthet-
ic also serves as a clinical indicator that the
medication was delivered accurately and that
the hamstring tendon was indeed the cause
of the patient’s discomfort.
The goals of imaging in the setting of ham-
string pain are threefold—to confirm injury,
to provide a comprehensive assessment of the
extent of the injury, and to identify which pa-
tients may benefit from intervention. In our
study, both MRI and ultrasound were found

to be helpful in determining the extent of the
injury and detecting imaging findings sugges-
tive of tendinopathy in patients with clinical
symptoms suggestive of high hamstring ten-
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dinopathy. However, MRI was more sensitive
overall in detecting both chronic and acute-
on-chronic hamstring pathologic abnormali-
ties, particularly peritendinitis. Peritendinous
fluid or edema was seen in 62.9% of patients
on MRI, compared with only 20% on ultra-
sound. As would be expected, MRI was the
only technique capable of detecting associ-
ated bone marrow edema within the ischial
tuberosity. At the same time, ultrasound was
able to detect calcifications in the hamstring
tendons in a subset of patients, findings that
were not apparent on MRI. The main advan-
tage of ultrasound is the real-time imaging
capability and excellent spatial resolution,
which allows targeted therapy.
The ultrasound findings were compatible
with the MRI findings in 13 of the 35 pa-
tients, revealing peritendinitis in three pa-
tients and tendinopathy in four patients. In
six patients, the hamstring tendons appeared
unremarkable on both the ultrasound and
MRI studies. The imaging studies were dis-
cordant in 22 patients, with 20 studies show-
ing abnormal findings on MRI that were not
apparent on ultrasound (16 peritendinitis and
four tendinopathy). In two patients, there
were positive findings of peritendinous fluid
on ultrasound that were not apparent on the
MRI. However, these differences may be
due, in part, to the time interval between the
original MRI scan and subsequent ultra-
sound. Although MRI is quite sensitive for
detecting peritendinous edema, it is possible
in some cases that ultrasound might be able
to detect small amounts of fluid that are not
obvious on MRI. Similarly, the absence of
findings on ultrasound may be due to resolu-
tion of edema during the time interval be-
tween the MRI and ultrasound. To provide
rigorous comparison on the sensitivity of
MRI and ultrasound, a much shorter time in-
terval between studies would be needed.
Our findings suggest that MRI is more sen-
sitive overall than ultrasound in the diagnosis
of proximal hamstring pathologic abnormal-
ities. However, ultrasound imaging is more
readily available and may be considered a
reasonable alternative for initial diagnosis
and treatment, reserving MRI for evaluating
cases where the first attempt at therapeutic
intervention is not effective. This is consis-
tent with the study conducted by Unverferth
and Olix [19], who reported that ultrasound
AJR:195, October 2010 997
Imaging of High Hamstring Tendinopathy
approximates MRI in depicting acute ham-
string injuries where peritendinous fluid may
be the predominant imaging finding, whereas
MRI is more sensitive for follow-up of chron-
ic hamstring injuries where tendinopathy may
be the predominant imaging finding.
It is notable that neither MRI nor ultra-
sound was highly sensitive in defining an ab-
normality of the hamstring tendons as the re-
sponsible pain generator. Nearly 23% of MR
studies and 62% of ultrasound studies were
considered normal; however, a substantial
number of patients with normal studies ben-
efited from corticosteroid injection. These
results underscore the importance of having
a skilled clinician for patient assessment, re-
ferral to diagnostic imaging, and referral for
imaging-guided injection.
In general, ultrasound-guided interventions
are increasingly being used as adjuvant treat-
ment in chronic musculoskeletal pain [11, 13–
17, 21]. Our study confirms that ultrasound-
guided corticosteroid injections are a safe and
effective treatment in patients who are recalci-
trant to conservative management. All but nine
of the patients in our study reported immediate
symptomatic improvement after injection of
the local anesthetic, confirming that the ham-
string tendon was indeed the cause of their dis-
comfort. No significant side effects or compli-
cations were reported by any of the patients
undergoing injection. Furthermore, there was
an excellent clinical response to corticosteroid
injection, with 50% of patients reporting mod-
erate-to-complete resolution of their symptoms
for at least 1 month after the injection and
28.9% reporting complete and sustained reso-
lution of symptoms postinjection. Even though
some patients did experience complete pain
resolution after the injection, an adequate treat-
ment plan should also include physical therapy
and activity modification to allow healing. In
the population reported here, inciting activities
such as long-distance running or sprinting were
curtailed but patients were engaged in cross-
training sports or deep water pool running to
maintain overall fitness.
The only imaging characteristic that was
associated with a statistically significant im-
provement in outcomes was the absence of
findings on ultrasound. We hypothesize that
those patients with normal ultrasound find-
ings likely had more mild injuries that per-
haps would have resolved on their own over
time. In these patients, MRI would not be
useful to further characterize their condition.
Conversely, in patients with abnormal ultra-
sound examinations, further trials would be
necessary to evaluate whether MRI could be
useful in further characterizing their injury
and possibly predict which patients would
benefit from intervention. In our discussions
with study participants, we also observed a
trend that those patients who had longer pe-
riods of rest and physical therapy before re-
suming their prior activity level experienced
longer lasting relief of symptoms. Subsequent
studies are necessary to further evaluate the
relationship of rest to overall symptom reso-
lution. A more in-depth understanding of the
pathophysiologic features of hamstring tendi-
nopathy and associated imaging findings may
help predict which patients would benefit
most from intervention. A prospective study
correlating imaging findings with symptoms,
response to treatment, and clinical outcomes
would further elucidate the mechanism of
chronic tendon degeneration and repair. This
knowledge may, in turn, benefit future studies
looking at the potential of biologic therapies
for treatment of tendon pathologic abnormal-
ities, such as platelet-rich plasma injection
[22, 23], a technique for which there are no
published data on hamstring tendinopathy at
this time, to our knowledge.
This study has several limitations. We were
unable to identify a matched control cohort
of patients who did not receive corticosteroid
injection. However, 79% of our patients had
symptoms lasting longer than 6 months before
the injection, thereby in principle serving as
their own controls. The study was retrospec-
tive and relied on patient recall of symptoms
dating back to 2002 in some cases. There was
a variable time to follow-up for each patient,
and the time difference between MRI and ul-
trasound studies was relatively long, owing
to periods of conservative therapy undertak-
en between MRI diagnosis and ultrasound-
guided injection. Furthermore, the subjective
nature of the pain questionnaire used made
it difficult to standardize the effectiveness of
the procedure across the patients. Although
the results were favorable, too few patients re-
plied to the survey to allow rigorous statisti-
cal confirmation of our findings. As a result,
our findings do not help refine selection crite-
ria for patients to undergo proximal hamstring
injection. Therefore, a prospective, random-
ized study evaluating the MRI and ultrasound
imaging findings and efficacy of corticoster-
oid injections would be beneficial to evaluate
the true potential of this procedure.
In conclusion, the use of ultrasound-guid-
ed injections of corticosteroid and local an-
esthetic is a safe and effective technique that

can provide both immediate and long-term
symptomatic relief of proximal hamstring
pain in appropriately referred patients. Ad-
vances in ultrasound-guided interventional
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techniques allow accurate needle localization
to optimize the diagnostic and therapeutic ef-
fectiveness with minimal morbidity. This pro-
cedure should be performed in conjunction
with physical therapy and a progressive-
strengthening program to achieve optimal
results, and avoid recurrent injury leading to a
more prolonged period of convalescence. This
technique serves as an excellent adjuvant in
the treatment of chronic hamstring injuries
recalcitrant to conservative management.
Acknowledgment
We thank the Stanford Transactional Re-
search Integrated Database Environment for
performing the computerized search of our
imaging databases.
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