Point-of-Care Ultrasound Diagnosis of Proximal Hamstring Rupture

Rachel R. Bengtzen, MD, CAQ, FACEP; O. John Ma, MD; Andrea Herzka, MD

Disclosures

J Emerg Med. 2018;54(2):225-228. 

In This Article

Abstract and Introduction

Abstract

Background: Acute proximal hamstring ruptures can be a diagnostic challenge in the emergency department. The revealing sign of large posterior thigh ecchymosis is typically not yet present; the physical examination is limited due to pain, radiographs can be unremarkable, and definitive testing with magnetic resonance imaging is not practical. These avulsions are often misdiagnosed as hamstring strains and treated conservatively. The diagnosis is made after failed treatment, often months after the injury. Surgical repair at that time can be technically challenging and higher risk due to tendon retraction and adhesion of the tendon stump to the sciatic nerve.

Case Reports: The first case illustrates an example of how delay in diagnosis can occur in both emergency medicine and outpatient primary care settings. It also shows complications and morbidity potential for patients who warrant and do not receive timely surgical repair. The second case illustrates physical examination findings obtainable during the acute setting, and the use of point-of-care ultrasound (POCUS) in facilitating an expedited diagnosis and treatment plan.

Why Should an Emergency Physician Be Aware of This? Timely diagnosis of hamstring rupture is paramount to optimize patient outcomes for this serious injury. The best results are obtained with surgical repair within 3–6 weeks of injury. POCUS evaluation can aid significantly in the timely diagnosis of this injury. If the POCUS examination raises clinical concern for a proximal hamstring rupture, this may allow for earlier diagnosis and definitive treatment of proximal hamstring rupture.

Introduction

Several soft tissue injuries require an expedited referral to Orthopedics for surgical management to optimize patient outcomes. Proximal hamstring rupture, which often has deleterious outcomes with a delayed diagnosis, is one such injury. The current recommendation for most complete or near-complete tendon ruptures is surgical repair in patients medically appropriate to undergo this orthopedic procedure. A delay in diagnosis can lead to long-term morbidity if not surgically treated within 3–6 weeks. This is due to the potential for tendon adherence to the sciatic nerve, tendon retraction, and muscle atrophy.[1,2] This is a short time in which many steps, including obtaining a magnetic resonance imaging study (MRI), arranging an orthopedic clinic appointment, and scheduling the patient for surgery must occur for optimal outcomes. Patients with unaddressed hamstring ruptures can have long-term pain with sitting, weakness with ambulation, difficulty returning to sport and generating power during sprinting, and sometimes sciatica.[2]

The diagnosis of proximal hamstring rupture can be delayed, as it is often mistaken for a hamstring strain or contusion, which are followed over time for symptom resolution. The delay may be due to a potential lack of formal training about this rare disease entity, the paucity of a revealing large ecchymosis on the day of presentation, and challenges in examining a patient in acute pain. The aim of this article is to provide an increased awareness of this diagnosis and the utility of point-ofcare ultrasound (POCUS) to aid in this diagnosis.

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