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

Case Reports

Case 1

A 50-year-old female avid skier presented to the Emergency Department (ED) with hip pain. She was carrying skis out of her car when she slipped and fell on her buttocks with her left leg extended in front. On examination, there was no swelling or ecchymosis, but she was tender to palpation over her left buttocks. Her motor examination was limited due to pain, but her foot dorsiflexion and plantar flexion were intact. Her sensation and pulses were intact. Pelvis radiographs were negative for fracture or dislocation. She was diagnosed with a contusion or possible hamstring strain and discharged to follow up with her primary care physician.

About 2 weeks later she followed up with her primary care physician, who diagnosed a hip contusion and prescribed pain medication and stool softeners. Over the following 3 months she continued to have difficulty walking, and gained weight due to inability to exercise. She also experienced pain with sitting. Four months after the original injury, she was referred to an orthopedist. Her examination revealed an antalgic gait, and limited forward flexion due to pain in the posterior proximal thigh. On prone examination, she had no ecchymosis. She had tenderness to palpation over the ischial tuberosity and a palpable defect at the site of hamstring origin. She had a visible and palpable mass in the mid posterior thigh. She had 2/5 motor strength with knee flexion and no foot drop. Other distal neurovascular examination was unremarkable. An MRI revealed full thickness tear of all hamstring tendons, with retraction of about 11 cm.

An orthopedic subspecialist was needed who repaired the proximal left chronic hamstring avulsion, which required an additional distal incision to dissect out the tendon remnants, and an Achilles tendon allograft bridge augmentation. Sciatic nerve neurolysis was performed due to tendon scarring to the adjacent sciatic nerve.

Case 2

A 42-year-old active man presented to the ED after a waterskiing injury. He was being pulled up out of the water starting a skiing run when he felt and heard a pop to his right posterior buttocks. He had pain with walking and sitting during the car ride, and presented to the ED on the day of injury.

On physical examination, vital signs were unremarkable. No pain was noted with log roll of hip; pain was noted in buttocks with hip flexion when knee was extended. Range-of-motion testing was limited due to pain. He had 5/5 strength to dorsi-/plantar flexion, and distal sensation was intact.

On prone examination, no ecchymoses or bulge was noted. There was a palpable defect just distal to the right ischial tuberosity that was very tender to palpation, reproducing pain. Pain to this location worsened when he attempted active knee flexion.

ED Course

Radiograph of pelvis was unremarkable: without fracture, avulsion injury, or dislocation. POCUS to ischial tuberosity revealed complete or near-complete proximal hamstring rupture (Figure 1A and Figure 1B). Due to this finding, an outpatient MRI was arranged, as well as a follow-up with a hip orthopedist after the MRI to discuss results and a treatment plan.

Figure 1.

(A) Complete hamstring rupture. Long axis view with gap present between tendon fibers and origin on ischial tuberosity (star). (B) Short axis view with no tendon bundle present above the ischial tuberosity (star).

MRI revealed a complete proximal hamstring rupture with 2 cm retraction. He had an uncomplicated surgical repair within 3 weeks from injury. With physical therapy he resumed running, had no residual pain with sitting, and returned to baseline activity.

Ultrasound Technique

Relevant anatomy. The origin of the conjoint tendon of semitendinosus and biceps femoris and the tendon of semimembranosus is on the posterolateral aspect of the ischial tuberosity. The muscle fibers arise a few centimeters distal to the origin of the tendon. The sciatic nerve is deep to these tissues.

Ultrasound. Place the patient prone or in lateral decubitus position with the affected side up, and the hip in slight flexion. Place the ultrasound transducer (either curvilinear or linear depending on patient body habitus) in the long axis to the hamstring tendons. Identify the hyperechoic ischial tuberosity as the primary landmark for the proximal hamstring tendons. Scan through the entire footprint of hamstring tendons and evaluate for an organized, linear homogenous appearance of normal hamstring tendons on the long axis (Figure 2A), and a discrete tendon bundle on the short axis (Figure 2B). A complete tear is characterized by hypoechoic presence of hemorrhage and complete absence of tendon at the ischial tuberosity, potentially with retraction (Figures 1A and Figures 1B).[3,4] A partial-thickness tear appears as hypoechoic cleftswithout tendon retraction (Figure 3). In a complete rupture, continue to scan distally to locate the retracted tendon end (Figure 4).

Figure 2.

Normal ultrasound of proximal hamstring tendons at origin on ischial tuberosity. Long (A) and short (B) axis of proximal hamstring tendons at ischial tuberosity (star).

Figure 3.

Partial proximal hamstring tendon tear. Arrow at incomplete hypoechogenicity within hamstring tendon, no retraction of tendons from the ischial tuberosity (star), thus indicating partial tear. Image courtesy of Dr. Jerod Cottrill, MD.

Figure 4.

Retracted proximal hamstring tendon. Arrow at retracted proximal hamstring tendon in surrounding hypoechoic hematoma. Image courtesy of http://www.ultrasoundcases.info.

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