Point-of-Care Ultrasound Diagnosis of Proximal Hamstring Rupture

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


J Emerg Med. 2018;54(2):225-228. 

In This Article


Patients typically present after sustaining a sudden forceful leg extension. For example, waterskiing or slipping on ice and falling with an outstretched leg onto buttocks will produce this injury mechanism. Patients may hear or feel a pop, have significant pain to buttocks or posterior thigh with walking, and often present for care the same day as the injury. When asked, these patients can localize their pain to the ischium rather than the mid hamstring region, and this is an important distinction. Also, the patient may have sitting pain and describe the sensation of "sitting on a golf ball."

Patients can be difficult to examine due to acute pain and limited range of motion. Key physical examination assessment includes observing a stiff-legged gait (minimizing hip extension and knee flexion). Place the patient prone, where they will identify the main source of pain at the ischial tuberosity. A palpable defect may be felt just distal to the ischial tuberosity, instead of the rope-like proximal tendon bundle, where the tendons are no longer attached; it can be helpful to compare with the unaffected side. There may be the presence of a distally palpable mass due to the retracted tendon bundle. Patients will have weakness in holding the knee flexed in this prone position. The revealing sign of large ecchymosis is usually delayed 2–4 days and therefore will usually be absent on the initial presentation, but patients can be educated that if this ecchymosis appears, it is cause for additional concern for tendon rupture.

The differential diagnosis includes pelvis or hip fracture, dislocation, bone contusion, or hamstring tendon partial tear or muscle strain. In patients with a proximal hamstring rupture, pelvic radiographs are usually normal. Younger patients may have findings of an avulsion fracture at the attachment point on the ischial tuberosity. An MRI of the thigh with thin cuts through the ischial tuberosity is the imaging modality of choice for diagnosis of proximal hamstring injury; however, it does not have real-time practical application in the ED for care of these patients.

Given these challenges, POCUS can be particularly useful to evaluate the proximal tendon to assess for continuity to insertion, and differentiate this injury, for example, from a myotendinous junction tear or hematoma.[5]

Surgical intervention for hamstring ruptures is best performed within weeks of injury. If further time elapses, this may lead to further retraction of tendons, scarring of the torn tendons to the adjacent sciatic nerve, and muscle atrophy. Situations where patients are diagnosed months later can lead to more complicated surgeries where sciatic neurolysis is needed due to scarring of the nerve to adjacent tendons, or additional incisions to dissect retracted tendon stumps and augmentation of these retracted tendons with allografts.[2]