Imaging

Diagnosis
and
Prognosticati
on
of Hamstring
Injuries

CSS / Journal Reading

By :
Anggia Rohdila Sari, ,
S.Ked
Preceptor :
dr. Ali Imran Lubis, Sp.
Rad

 OBJECTIVE.

Hamstring injuries are

common in sports. Although management
and outcomes are sport specific, clinical
evaluation alone is a poor guide for
treatment planning and prognostication.
Cross-sectional imaging has added value
in these cases.

 CONCLUSION.

Specifically, the location

(tendon attachment, classic or intramuscular
myotendinous junction, or extramuscular
portion of the tendon), specific muscles
involved, and anatomic extent are factors
that can influence the immediate treatment,
expected convalescent period, and risk of
recurrence in these athletes.

 Muscle

injuries account for up to half of all

injuries in some sports and are a common
reason for lost playing time.

MRI

or, in some cases, ultrasound can help

the
treating
clinician
optimize
initial
treatment and plan convalescence and
rehabilitation to minimize the impact on the
players and teams well-being.

Relevant Anatomy

The semimembranosus, semitendinosus, and biceps

femoris form the hamstring group.

The proximal tendons of the semitendinosus and

long head of the biceps femoris merge to form a
conjoint tendon, which takes its origin from the
inferomedial facet of the ischial tuberosity; the
semitendinosus also has a secondary muscular
origin from the inferior ischium

The short head of the biceps femoris has a muscular

origin along the linea aspera of the posterior femur

long
proximal
tendon
of
the
semimembranosus originates from the
superolateral facet of the ischial tuberosity,
slightly anterolateral and cranial to the
conjoint tendon origin.

The

proximal semimembranosus tendon is

approximately twice the diameter of the
conjoint tendon

 The

two heads of the biceps femoris compose

the lateral hamstring muscle group and
distally give rise to a tendon that merges with
the fibular collateral ligament of the knee to
insert on the lateral aspect of the fibular
head. A second smaller tendon slip inserts on
the proximal lateral tibia

Distally,

the semimembranosus has a central

tendon insertion on the medial proximal tibia
and at least four minor tendon slips attached
to various supporting soft-tissue structures of
the knee

Clinical Diagnosis, Management, and

Outcomes
Hamstring Avulsions
Avulsions

of the hamstring attachments are

much less common than muscle strains, and
distal avulsions are particularly uncommon as
isolated injuries
Avulsions of he proximal hamstring tendons
from the ischial tuberosity affect the conjoint
tendon more frequently than the biceps femoris
tendon
alone;
avulsions
of
the
semimembranosus origin are rare

 Complete

injuries with or without tendon

retraction are more common than partial tears,
and most authors advocate immediate surgery
for complete avulsions.

Patients

who are treated conservatively and

for whom treatment fails can still undergo
delayed repair, but this often means a more
difficult operation and poorer outcomes.

Recovery

times range from 3 to 18 months

[18], with 80% of athletes treated surgically
able to return to sports within 6 months

Typical Hamstring Strains

Classic

hamstring strains result from rapid

accelerations, decelerations, and changes in
direction , in such sports as track-and-field,
soccer, and American football
Prior

lower extremity trauma, older age, and

deconditioning are contributory risk factors in
some studies

 Strains

most commonly involve the proximal

myotendinous
junction,
followed
in
frequency
by
the
intramuscular
myotendinous
junction,
the
distal
myotendinous junction, and finally the
myofascial junction

Athletes

experience a sudden sharp pain in

the back of the thigh, sometimes with an
audible pop.

 Initial

treatment of muscle strains follows the

PRICE principle: protection, rest, ice,
compression, and elevation.

Analgesics

or nonsteroidal antiinflammatory
drugs are used for pain control

Ideally,

players will not return to play if there

is a persistent muscle strength deficit
(compared with the contralateral side), but
the decision is usually predicated on
functional testing

 So

in sports such as soccer and American

football, the mean time to return to play is 2
weeks, while for elite sprinters the average is
16 weeks, eight times longer.

However,

within each sport, there is a very

wide range of recuperation times (e.g., 1128
days in professional soccer players.

Importantly,

the clinical severity of the initial

injury cannot predict the expected recovery
time

 In

general, the injured part of the muscletendon unit does not predict return to play,
with one important exception: in highperformance
sprinters,
proximal
biceps
femoris strains may extend proximally to
involve the free tendon, and, in these cases,
recovery takes, on average, three times longer
(35 weeks vs 12 weeks when only the
proximal myotendinous junction is injured).

However,

it is not possible to tell whether the

injury extends into the proximal tendon by
palpation alone.

Atypical (Stretching) Hamstring Strains

These

atypical hamstring injuries differ from

the more common classic strains in several
important ways.

First,

the initial symptoms may be relatively

mild, with some athletes able to finish their
activity after the acute injury.

Women

are affected more than men are.

 Finally,

these injuries take much longer to

heal, with a mean recovery time of 50 weeks
in dancers and 31 weeks in other athletes. In
one report, 47% of these atypical hamstring
strains were career ending.

Imaging Diagnosis, Treatment

Guidance, and Prognostication
For

suspected proximal tendon avulsions, the

role of imaging is twofold.

First,

it may be impossible to determine with

physical examination alone whether a strain or
tendon avulsion is present, with the latter
typically requiring immediate surgery .

 Fractures,

proximal hamstring tendinopathy,

ischial bursitis, ischiofemoral impingement,
and iliopsoas tendinitis can also potentially
mimic a proximal tendon avulsion, and these
conditions are easily identified with MRI.

Second,

once a diagnosis of an avulsed

tendon is made, imaging is typically used to
guide treatment planning.

 The

key observations to note are whether the

conjoint
tendon,
the
semimembranosus
tendon, or both are involved and whether the
tear is partial or full thickness.

For

fullthickness tears, the amount of distal

tendon retraction, the degree of underlying
tendinopathy, and the relationship of the torn
tendon ends to the sciatic nerve influence
treatment planning.

 One

final issue is whether there are imaging

features that can help predict recurrent
injuries.

Most

hamstring injuries will heal with a

variable amount of scar tissue, and the player
will be able to regain their former level of
performance. However, injury to the same
thigh will reoccur in the same or next season
in approximately 15% of those injured.

 In

Australian football players, the length of

the initial injury on MRI is associated with the
risk of a second hamstring strain in the same
season, with a 33% recurrence risk if the
original extent of muscle edema is greater
than 6 cm long, but only 7% otherwise.

Players

with MRI-negative injuries have

virtually no increased risk of recurrence

152-year-old
man
with
proximal
hamstring
avulsion
resulting from
waterskiing
injury 4 weeks
previously.

Coronal STIR image shows complete tear of left

conjoint tendon origin (black arrow) and intact right
tendon origin (white arrows). There is mild distal
tendon retraction.

Transverse T1-weighted image shows torn tendon

stump (long arrow) separate from sciatic nerve (short
arrow), which is surrounded by fat. Because of small
amount of retraction and normal sciatic nerve, injury
was managed nonoperatively and healed.

248-year-old
woman with acute
proximal hamstring
avulsion.

Coronal

STIR image
shows severe distal
retraction of torn
hamstring tendons
(arrow), with large
surrounding
hematoma.

Transverse T1-weighted image through ischial

tuberosity shows complete tendon avulsions on right.
On left, note normal semimembranosus tendon (long
black arrow), normal conjoint tendon (short black
arrow), and sciatic nerve (white arrow).

Transverse fat-suppressed T2-weighted image through

proximal thigh shows large hematoma enveloping distally
retracted semimembranosus tendon (black arrow) and
sciatic nerve (white arrow). At time of surgical repair, torn
tendons were scarred to sciatic nerve.

330-year-old man, offensive lineman on professional

football team, with grade 1 central myotendinous biceps
femoris strain.

Transverse fat-suppressed T2-weighted image shows

intramuscular edema surrounding long-head biceps
femoris central tendon (arrow) and in deep fascia.
Approximately 50% of muscle cross-section is involved.

Coronal STIR image

shows
typical
feathery edema in
bipennate muscle
fibers
(arrows)
converging
on
central tendon.

427-year-old man, offensive guard on professional football

team, with grade 1 peripheral (myofascial) biceps femoris
strain.

Images of thigh show edema confined to lateral

margin of long-head biceps femoris muscle (arrow,)
involving approximately 10% of muscle crosssection.

 Coronal

STIR image shows extent of injury at

lateral myofascial junction (arrows).

 523-year-old

man with grade 1

distal
myotendinous
hamstring strain.

Sagittal fat-suppressed
fast spin-echo image
shows edema centered
between distal muscle
belly (black arrow) and
tendon (white arrow) of
semitendinosus

 Transverse

fat-suppressed T2-weighted image

shows involvement of entire cross-section of
distal muscle (arrow)

 618-year-old

man with grade 2

biceps
femoris
strain.

Coronal

STIR
shows

image
high-signalintensity
gaps
between muscle
fibers.

 Transverse

T1-weighted
image
shows
hyperintense subacute hematoma (arrow) in
biceps femoris muscle.

 Sagittal

STIR
image
through
left thigh shows
extent
of
intramuscular
hematoma.
Aspiration
of
hematoma was
performed under
ultrasound
guidance once it
had liquefied.

33-year-old male elite marathon runner with

proximal hamstring strain sustained during prerace
stretching

Transverse fat-suppressed T2-weighted image

through proximal thigh shows edema throughout
semimembranosus muscle, with surrounding fascial
edema.

Transverse fat-suppressed T2-weighted image more proximally, at

level of ischial tuberosities, shows extension of injury surrounding
proximal free tendon (arrow).
There was no tendon avulsion. Injury of semimembranosus and
involvement of free tendon is characteristic of stretch-induced
injury and portends very lengthy recovery.
At last follow-up, patient was still unable to run after 6 months of
rest.

Thanks