Summary

This pilot case series indicates that both operative and non-operative treatment for proximal hamstring tendon avulsions can result in return to play and return to performance in elite athletes following shared decision-making.

Abstract

Introduction

Proximal hamstring tendon avulsions are rare but severe hamstring injuries, that have the potential to end an athlete’s career. Operative treatment is the most described choice of treatment for these injuries in current literature. Non-operative outcome is scarcely reported, even more so in elite athletes. Therefore, the objective of this case series was to describe the outcome of both operative and non-operative treatment in terms of return to play and return to performance in sports for elite athletes.

Methods

we included elite athletes with MRI-confirmed proximal hamstring tendon avulsions of the conjoint tendon and/or the semimembranosus tendon. Operative or non-operative treatment was selected by shared decision-making. For operative treatment reattachment with suture anchors was performed followed by a phased criteria-based rehabilitation program. Non-operative treatment consisted of a phased criteria-based rehabilitation program. The primary outcome was time to return to performance (in days). Secondary outcomes were time to and rate of return to play, return to performance rate, and recurrence rate.

Results

In total we have included nine proximal hamstring tendon avulsions in eight elite athletes with a median age of 27 years (IQR: 23 – 29 years). Five athletes were treated operatively and three athletes were treated non-operatively. One non-operatively treated athlete sustained a proximal hamstring tendon avulsion in different legs on different occasions. Operative patients included three full-thickness avulsions of both conjoint and semimembranosus tendon and two full-thickness avulsions of the conjoint tendon. In the non-operatively treated cases there were two full-thickness avulsions of both conjoint and semimembranosus tendon and two full-thickness avulsions of the conjoint tendon. The median retraction of the affected tendons in the operative group was 51 mm (IQR: 24 – 78 mm) and the median retraction in of the affected tendons in the non-operative group was 39mm (IQR: 25 – 46 mm). The median return to performance in days of the operative group was 395 days (IQR: 240 – 472 days) and in the non-operative group 120 days (IQR: 74 – 235 days). The median return to play time in days of the operative group was 304 days (IQR: 159 – 351 days) and in the non-operative group 63 days (IQR: 50 – 95 days). Both groups had a return to play and return to performance rate of 100% without recurrences.

Conclusion

This pilot case series indicates that both operative and non-operative treatment for proximal hamstring tendon avulsions can result in return to play and return to performance in elite athletes following shared decision-making. Non-operative treatment might result in return to play and return to performance quicker, but larger samples sizes are required, as well as long-term outcomes to determine whether operative treatment is an investment in superior long-term outcome.