WHat is a proximal hamstring tear?
The hamstring muscles run from the buttock down the back of the thigh and across the back of the knee. Most hamstring injuries occur in the middle of the muscle and will heal completely without the need for surgery. However, when the hamstrings are injured at the top end, the tendon can pull off the bone. In this case, surgery is recommended to reattach the damaged tendons. Sometimes repetitive minor injuries can cause the tendons to become thickened, frayed and painful. This is called tendonosis. Surgery may also be helpful for this condition, but is only considered if all other methods have not worked.
HOW is a proximal hamstring tear diagnosed?
The most common way the hamstring tendons are torn is during a slip or fall in which your leg is stretched out in front of you (as in doing the splits). This can happen during sports such as waterskiing, martial arts, rugby, or even a simple slip on wet ground. Most people will experience severe pain in the buttock region and significant difficulty walking. Major bruising on the back of the thigh is common, appearing a few days after injury. A tear can often be identified with a careful physical examination by a trained specialist. Proximal hamstring tears are generally not seen on x-rays. While diagnosis can sometimes be made with an ultrasound scan, the most reliable way to assess the amount of damage is with an MRI scan.
Who Needs Surgery?
There are three hamstring tendons. When only one or two are damaged then these can heal without surgery. When all three hamstring tendons are pulled off, they will retract from the bone and in this case surgery is recommended. Patients who do not have surgery will experience a loss in strength and endurance in this leg. Non-surgical treatment results in approximately 50% strength, while those having repair will regain about 90% strength. Surgery has the best results when done early (within six weeks). Patients with tendonopathy (thickening and pain) are recommended to try anti-inflammatory medications, physiotherapy and steroid injections before considering surgery.
The Operation
You will require a general anaesthetic, and will lie on your stomach for the operation. The surgery is done through either a 10-15cm transverse (sideways) or longitudinal (lengthwise) incision over the buttock crease. The main (sciatic) nerve sits next to the hamstrings, so this must be located and protected. The torn tendons are reattached to the bone using suture anchors, which sit inside the bone. If the tendon has retracted a long way from the bone, some of your own tendons may be taken from your knee to fill the gap. The skin is closed with a dissolving stitch. The operation takes between 90 minutes and 4 hours depending whether a tendon graft is needed.
What is the recovery after surgery?
First 24 hours post-surgery
You will be taken to a ward to rest in bed. Your nurse will provide pain relief medication. If a nerve block was used then your leg will be numb for 24 hours.
You may have a brace on your leg to prevent damage to the tendon repair.
Day 1-2 post-surgery, in hospital
Mr Gormack will check on you each day while you are in hospital.
A physiotherapist will visit you and teach you how to walk using crutches. You will be allowed to touch weight bear only.
You will be able to go home 1-2 days after surgery, once you are comfortable and safe getting around by yourself.
First two weeks post-surgery
Continue to walk touch weight bearing using crutches and a brace if this has been provided.
Keep the wound covered with the dressing placed in hospital.
Take oral painkillers and anti-inflammatories.
Contact Mr Gormack’s clinic to arrange an appointment for two weeks post-surgery.
Weeks 2-6 post-surgery
You can now begin to partially (50%) weight bear with crutches. The brace can be discontinued.
You should not start physiotherapy, stretching or strengthening exercises as the tendon still needs time to heal onto the bone.
After six weeks
You can start walking without crutches, increasing distances as comfortable.
You can begin gentle exercise on a exercycle/stationary bike with low resistance. Sitting on a bike may still be uncomfortable so extra padding may be needed on the seat.
After 12 weeks you can start gym-based strengthening exercises and physiotherapy.
Resuming full activities and sport will take 6 - 12 months.
Additional information
Sitting discomfort. Due to the location of the tendon repair and wound, sitting may be painful for up to six weeks. Some discomfort with prolonged sitting may persist for 6 – 12 months.
Infection. Wound infection is uncommon (1-5%), but can be a serious complication. To minimise the risk make sure the wound is dry and covered for the first two weeks. Increasing pain, redness and feeling generally unwell can be signs of infection and should be treated urgently with antibiotics. In rare circumstances, further surgery may be required to deal with a persistent infection.
Nerve damage. After surgery, all patients will have some local numbness around the scar. The main (sciatic) nerve to the leg runs very close to the hamstrings, and can be trapped in scar tissue. It needs to be found and moved out of the way during surgery, and is at risk of being bruised or damaged. Damage to this nerve causes numbness in the leg and foot, and weakness in lifting the foot (foot-drop). It can also cause nerve pain. In most cases, this is temporary and will recover by itself. There is a very small chance (0.1%) of permanent nerve damage.
Blood clots. Blood clots are possible after any lower limb surgery, and can be harmful if they travel to the lungs. If you are high risk for blood clots, or need to fly or drive a long distance in the first six weeks after surgery, then a blood thinner tablet (aspirin) or injection (Clexane) may be recommended.
Return to work. If you have an office-based job, returning to work should be possible between 3-6 weeks following surgery. If you have a more physical job, light duties are possible at 2-3 months, and full heavy physical work at 4-6 months post-surgery.
Re-injury. If you are careful then re-injury should not occur. Remember that the damaged tendons have to heal onto the bone, and that this bond takes six months to become strong. Any excessive force during the first six months post-surgery risks re-rupture.