All right, so welcome everybody to the Multi-Institutional Sports Medicine Fellows Conference which tomorrow you'll learn from Mark Miller, actually a better acronym for it. So we'll keep you, you know, that's your teaser for tomorrow. So please keep your microphones muted. This is being recorded. It'll be transferred to the OSSM playbook on their website. It'll be on their learning management system and will be available, this week's will be available starting next week. And they're gonna keep basically a log of all of these from this whole series that we put together. If you have any questions, please submit them on the chat function. And at the end, I will bring them out to Dr. Cohen and the rest of the faculty. Any faculty, let me know and I'm happy to unmute you now that I can figure that out. Unmute you for comments. And without further ado, we are quite honored to have Steve Cohen, good friend, professor of orthopedic surgery at Rothman and Jefferson. He's the head team physician for the Philadelphia Phillies, team orthopedist also for the Flyers. He's done a lot of work on hamstring injuries from back from the day when he was a fellow and continues on to have a particular interest in that. So he's very kind to share his thoughts again, as he's been doing this for a couple, almost two decades almost, right, Steve? So on this topic. So he has a lot of knowledge and expertise to share with us. So without further ado, Steve, thanks so much for doing this. Thank you, Mark. I'll go to one and a half decades if you want to go that route. But so I appreciate the invitation. I know Mark and I have had conversations about treatment of hamstrings in the past. So I'm really glad to participate in this. My disclosures are on the AOS. I do want to thank Peters Ottlunds, who's one of our fellows. He did a presentation on this earlier this year to our group. I did use a few of his slides. So I appreciate his help. Excuse me. So we're going to talk about proximal hamstring injuries. First, increasingly diagnosed, I think more because of recognition and the fact that there's a treatment in both young, but more predominantly middle-aged patients. And we're going to talk a little bit about the epidemiology as we go. But the issue is that these often can be debilitating outcomes if left untreated. And we all have seen patients that have come into the office that had an injury three, four months, or even a year ago by, and nobody really took the time to diagnose them. And if they're active, it can be really problematic. And these are really a subset of hamstring injuries that are far less common than the typical pull hamstring or the hamstring strain, which involve the myotendinous junction and are more intramuscular. So just as an outline, we'll go over the anatomy and the mechanism of injury diagnosis and examination, surgical technique. We'll go through a little lit review. And at the very end, we'll touch a little bit about distal injuries. And for the fellows on board, there are gonna be a couple of questions that I want some participation in. I believe that there's a way to react below by hitting a thumbs up. So you'll know when that time comes. So it all starts with anatomy. Jack Houston always said that if you know the anatomy, you're in good shape. Recreating the anatomy is the best thing we can do. So the hamstring origin is really on the lateral portion of the ischial tuberosity. It's really a oval shaped attachment with the biceps femoris and the semitendinosus attaching more medially. And that really encompasses about two thirds of the insertion and the semimembranosus is lateral. And you can kind of see the shaded area that the semit and the biceps are typically what's referred to as the conjoined tendon. I will say that, and we'll get into this a little bit later, but for usually complete tears, they really do come off together. And that term can also be kind of looked at as a quote conjoined tendon or the big group of tendons. Talking a little bit about some of the anatomy and looking at it. If you look here on the screen, hopefully my cursor kind of shows up. Here is the ischial tuberosity. This is a right side kind of face down. Number one is the conjoined tendon. So that's the semit and biceps together. Just lateral to that is the semimembranosus. And this big wide structure right here listed as number four should be no surprise, but that's the sciatic nerve. We'll talk a little bit about the risk of this, but obviously I think that I find it really interesting that some of my partners that do hip arthroscopy, my two main partners actually don't do hamstring repairs. It kind of boggles my mind that you're a hip surgeon and don't consider doing this. But I think that the nerve and the type of injury, it definitely impacts people's ability to do this. The sciatic nerve is in general on average about 1.2 centimeters from the lateral most aspect of the ischial tuberosity. So not too, too far. At the lateral ischium, the inferior gluteal nerve and artery are about five centimeters to the inferior border of the gluteus maximus. So again, these are all structures that we need to be aware of if you're gonna operate in this area. Well, what's the typical mechanism of injury? If you go back and we'll cite some of the literature from the 90s, and this is when it was most commonly recognized as an injury. The water skiers, and I'll have to use my Philadelphia accent of water as not a water skier, but it's an eccentric hamstring contraction, basically with the knee and extension and the hip inflection. So just as you see getting pulled out, the cord kind of gets pulled forward when they straighten the knees and your body goes forward, this is the exact mechanism. And I will tell you that the more common mechanism of injury is a slip and fall onto like a wet floor or even on a slope or an incline. That is probably the most common mechanism as opposed to a water skiing. Now here's another mechanism of injury, and you may get a little audio to this too. This is one of our pictures from about three, I guess four years ago now. And when it goes back, you can actually see his left arm, left hand, he's grabbing his buttock area. And fortunately we have video guys that get 18 different angles. Here's the next one. So he immediately grabs his left buttock, and he knows right away that there's a problem. We'll talk a little bit about him in a second, about treatment, about what he did and what he's accomplished, and somebody can put on the chat if they want to, if they can recognize who that was in that short period of time. So history of eccentric injury, that's probably the biggest history portion of it, knowing the type of injury, how their knee went, how their hip went. On exam, they're typically going to have this ecchymosis. Now, you can certainly get ecchymosis around the posterior thigh with a hamstring strain, but it's pretty dramatic with these proximal hamstring avulsions. And so I think as soon as you see that, then you pretty much should be concerned about it and the idea. So sitting pain is another common one. Weakness, you may or may not have a palpable defect depending on the size of the thigh, the buttock region. You may or may not feel a palpable defect. You always want to get a good neurovascular exam. You want to assess the sciatic nerve function, so dorsiflexion of the foot, plantar flexion. You want to test sensation in the foot and in the posterior aspect of the thigh. And if nothing else, if you really haven't gathered nothing else from this hour that we're going to spend together, if you have a high clinical suspicion, then at least you'll have that ability to make the diagnosis. So we're going to talk a little bit about some special testing. And Mark and I have had this conversation about what kind of tests that we use to help diagnose not only hamstring strains, but proximal hamstring evulsions. So the first one that I use is a prone straight leg raise. And I'll ask the patient to do this prone straight leg raise with their good leg first, test their strength, and then their opposite leg. The second thing I'll do, and again in the prone position, is to test knee flexion at 90 degrees, at 45 degrees, and then at 15 degrees. And the reason why I do this is because we have to think about the shortening and lengthening of the hamstring. So as you can imagine, it's longest in full extension of the knee and shortest in knee flexion. So typically with a routine hamstring strain, if somebody has a pretty mild strain, then at 90 degrees they're not going to be too problematic. At 45 degrees, again, same thing. And at 15 degrees, as you extend them out and really lengthen the tendon, you'll get more symptoms. It's not hard and fast, but a grade two injury, they're going to have more symptoms at 45 and 15 degrees, and a grade three injury, a really high grade hamstring strain, they're going to have, you know, at all three positions. And again, very similar to a proximal hamstring evulsion, that if they are symptomatic at all three, then you really have to have a high clinical suspicion. Another test that I'll use is a supine bilateral plank. And here you can see the knee is pretty much flexed a little beyond 90 degrees. But what I do is I'll bring them out to 45 degrees and then bring them out to 15 degrees. And again, the same thing. The more flexion they're in, the easier contraction they have on their hamstring. The more extension they're in, the harder it is. Now this next test is probably the hardest test. And, you know, I would encourage you to even actually try this yourself because it is actually very difficult even on a healthy leg. But it's really, it's one that when you're rehabbing somebody and you can test them, it's, you really want to get them on their forearms, kind of leaning up. And then you want to raise their bad leg first. And then with their good leg, you want to, in full extension, try to get them to lift their, do a plank by lifting their buttock and body and trunk off of the bed. Then we switch legs and have them do the affected leg. And clearly with a proximal hamstring avulsion, you're going to have a very difficult time with this. But I think it's really a good test to look at with regard to, particularly as you rehab somebody because they'll come back three months after surgery and say, hey, gosh, you know, I feel great. You ask them to do this plank test and you can really assess the quantity of their weakness and the quality of their strength. Another one is typically more used for hamstring strains as opposed to avulsion, but a standing heel drag test where, you know, their knee is bent, they're dragging their heel along, and they're really testing the posterior musculature. Well, how about imaging? Typically, x-rays are really not very productive as far as what you see. But occasionally, you will see this. And there's nothing like the red circle test or the diagnostic test that the radiologist will give you, an arrow, a big circle. But this is a big calcification from the fact that he ripped off his ischial tuberosity with his hamstring, and this was actually a middle-aged patient. It's a little bit more common in the younger patients with open physis, but you definitely can see this. So I would encourage, you know, people who come in and say, well, I strained my hamstring. Why would I need an x-ray? Well, this is not something that you want to miss. MRI is certainly the gold standard, MRI of the pelvis. If you're going to order the test, if you get the MRI of the pelvis, try to ask them to include the upper thigh so that you can compare side to side and also look for retraction. If you get an MRI of the thigh, occasionally, they won't get proximal enough to be able to see the ischial tuberosity. So know your radiology department, know, and if you have to talk to them or add an additional note, just tell them, get an MRI of the thigh but include the ischial tuberosity or vice versa. So here, you want to assess for complete three-tendon tears, partial tears, and again, look for intramuscular strains, musculotendinous junction injuries. And this is probably the most diagnostic MRI that I think that you can look at. I predominantly look at the coronal and axial images, but a sagittal image certainly can be helpful with regard to retraction. But here is really what you want to do is, here is the left side, here's the right side, here's the ischial tuberosity right in a good plane. And the dark spot coming off of that, that's our proximal hamstring insertion onto the ischial tuberosity. When you have an acute tear, you see the space, you see the amount of retraction, you see the hematoma, and then you go to your axial view, and again, the same thing, big, thick insertion onto the left side of the ischial tuberosity and a blank ischial tuberosity over here on the right side, kind of like looking at a rotator cuff looking at the humeral head. So very important that you look at multiple views to do this evaluation. The Crescent sign, and I know Justin Arner is on this call, and we'll get a little bit into some of the research and the publications and what he's done for this and has done a lot of good work on looking at partial tears, and here you can see the arrows, but you can see kind of a centralized defect at the ischial tuberosity and the fluid underlying it, and that's a central intratendinous tear. Again, Justin, he coined the term sickle sign, which is that central partial tear, and here is a three-tendon complete proximal hamstring tear. Several classifications, you know, we all are familiar with the traditional radiologic strain grade over here on the right, but would describe this classification looking at five different types from the osseous avulsion, which oftentimes, again, needs to be fixed, to the musculotendinous junction injury, which, again, is unlikely to require any type of operative management. Incomplete avulsions, again, these partial tears that are usually amenable to non-operative treatment initially and may end up going on to surgery. Complete tears with very minimal retraction. Again, we can talk a little bit about whether you'd recommend surgery for that, but I would tell you that a complete tear oftentimes will typically, even with very minimal retraction, you think about surgical treatment. The type 5A is avulsion with retraction, and the 5B does involve the sciatic nerve. So, Matt Pombo was one of the fellows after me at UPMC presented, but didn't end up publishing this data on a proximal hamstring classification, but he looked at 32 patients, did a correlation with MRI, with the findings with surgery, and here's what it basically was. A one-tendon tear was a type 1 injury. 1A is no retraction or less than 2 centimeters. 2B is one tendon with 2 centimeters of retraction. Type 2 is a two-tendon tear with minimal retraction, greater than 2 centimeters, and then kind of this inverted cone or this high-grade partial tear that I think you see on the MRI scan that Justin described, and here you can kind of see that sickle sign. And they can vary in the degree of severity. Type 3 is the three-tendon tear with and without retraction. Type 4 is bony avulsion, again, less than 2 centimeters of retraction or greater than 2 centimeters of retraction. Again, here's a, and I would encourage you that if you do have a bony avulsion, a CT scan can certainly be very helpful to help quantify this for you. And a type 5 was just described as acute on chronic. As far as treatment goes, the first-line treatment for, you know, most hamstring strains, again, is going to be non-operative treatment. We think about active rest, anti-inflammatories, physical therapy focused on, you know, stretching and strengthening of the hip, the core, as well as the quadriceps. You know, Nordic hamstrings, I think Lyle described this yesterday, and that's another test that if you haven't ever tried, I would encourage you to make an effort to do this because you'll be surprised at how deficient you feel like your hamstrings are when you do this. Other non-operative treatments such as, you know, shockwave therapy. And then, you know, there's the injections of either corticosteroid or PRP. You know, some people have described aspirating large hematoma for strains as well as PRP injections and Jim Bradley, who obviously has done, you know, a lot of the work and pretty much where I learned the majority of the things I know about the hamstring has been a pioneer in this. When do we surgically repair? We published the Yellow Journal, the Journal of Academy study in 2007 and basically looked at recommended surgery for three tendon tears, two tendon tears with two centimeters or more of retraction. Patients with one or two tendon tears that have less than two centimeters of retraction that fail non-operative treatment. And again, you know, these high-grade partial tears, again, that fail non-operative treatment. Again, this is the citation that we published in 2007 with Jim. This is typically the positioning. They're in the prone position. If you can, get them into this kind of reverse type of Trendelenburg with a little bit of hip flexion. It basically gives you a little bit more access to the initial tuberosity. Here's kind of the setting. Any of the fellows that have done this or have scrubbed with me know that unfortunately while you're prepping the leg, you're holding the leg up in the air and it's definitely good to have eaten your breakfast that morning because it certainly can get a little bit long. Talking a little bit about the actual surgical technique, I do predominantly, I would say nearly 100% of the time, a transverse incision across the gluteal crease. Where we put this depends on the amount of retraction, a little bit more retraction. We may lower it a little bit, a little less retraction or partial tears. We may center it just a little bit more over the initial tuberosity. But you really need to keep in mind that if you end up being high on this where you're not below the initial tuberosity, when you're drilling your anchors to put it in in this direction, you really need to be coming from a lower plane. You take the incision down to the gluteal fascia. You transversely split the gluteal fascia and this exposes the maximus. You want to retract this superiorly if you can. Depending on the size of it, you can split it and Jim Bradley has described that as well. I will tell you in that athlete, and I don't know if anybody put it on the chat, but that was Charlie Morton. As you can imagine, a young professional athlete, pretty strong glutes, pretty strong, pretty big posterior thigh musculature. You know, a little bit of work to get down to the area. So you need to be careful working down to that area. Once you elevate the maximus, you kind of come down to the first layer or this hamstring fascia. And when you split this, you think naturally, as soon as I split this, I'm going to, especially on acute tear with hematoma, you split this, you're going to get that hematoma. And unfortunately, that's not the case because that would make it a lot more simple. Then you kind of come down and you expose what I really describe as the paratenon of the hamstring. Excuse me. And when you get down to this level, once you split this, then you encounter the hematoma. And again, depending on the timing of your surgery, the hematoma looks brown. It's a fluid that you're not really comfortable seeing, particularly when you're in this area of the body. And the joke I often use is the brown fluid that you see coming out of the hematoma is kind of your reaction to it the first few times you do this as the operating surgeon. So here's what you get. Then you expose the tendon, you free it up, mobilize it, put a tag stitch in it. And then, excuse me, then what you want to do is expose the ischial tuberosity. Once you expose the ischial tuberosity, here's looking with the tendon kind of out of the, basically, you take it out of the plane of the incision. You can mobilize it. You can free it up. And you can debride the tendon of any of the abnormal tissue. And then once you expose the ischial tuberosity, then you're going to go ahead and put your anchors in. Now, Jim and I originally described putting in five anchors. I still do this. I know Jim has recently published some of the work looking at using seven and eight anchors. I can tell you that when we first described this, putting in five anchors, most people thought we were crazy. Because I would think that the majority of people were actually thinking about putting two and three anchors. The order that you do this is essentially you put the anchors from proximal to distal. So I put my two most proximal anchors in. I put a central anchor in. And then the two distal ones. There's lots of different ways to organize this. But it's really important that you organize it. What I do is I use four of the same hemostats. So I use four curved and one straight or vice versa. And I put the one, the single, either the straight or the curve that's different than the other one around the central one. That way I know exactly which one. The anchors go in from proximal to distal. Then we go ahead and pass horizontal mattress sutures from distal to proximal. And the idea is that we can gain our length from the inferior aspect of the tendon. And once you do that, you put your central one in, your two proximal ones. And then we then tie, kind of similar to how you would organize a rotator cuff, we then tie from proximal to distal. And the idea behind that is you gain your length all the way up to the very top part of your insertion on the initial tuberosity with your two proximal sutures. Then you tie from superior to inferior. And what that does is it lays the tendon down to the bone and creates a good solid footprint on the initial tuberosity. And here's what the finished product looks like. So proximal to distal, you tie down, you gain your length, and basically you're just laying down the footprint the rest of the way. So some tips and tricks that I've learned over the years. I use a headlight for this. Again, you know, you may be working in a deeper hole depending on the size of the patient. I feel comfortable with it. You know, my hand surgeon colleagues tell me that real surgeons operate with loops. I do. I use loops for this. It's kind of funny to think about. But you can identify the posterior femoral cutaneous nerve. I think it's helpful to look at some of the structures that you're working around. We're careful with our retraction. I use curved deevers for the most part, depending on the shape of the bone. And you might use a blunt homin along the initial tuberosity to retract laterally. You do need to be careful with this. The fellow is always working on the lateral, on the same lateral side with me, so that we can carefully and, you know, visualize and retract to see the tuberosity. You prepare the tuberosity with curettes and an elevator. Absolutely do not use a burr. And you need to be really cautious with using electrocautery in this area. You want to place your anchors under direct visualization, and you can insert them with a guide. I use anchors without needles. That way it's really easy to put them in, and then I'll go ahead and pass my horizontal mattress sutures by placing the needle through the suture. From a rehab standpoint, I do use a hip orthosis. I restrict them from hip flexion to 45 degrees. I allow minus 15 degrees of hip extension, so I allow them to extend but don't flex past 45 degrees. There's some debate and I'm sure the question might be what about using a knee immobilizer or a hinge knee brace locked in 90 degrees of flexion. I know Jim has gone back and forth with this and I know some surgeons use the knee flexion. I personally, while they can't sit up and sit in a chair at 90 degrees, I personally do not feel comfortable leaving somebody at 90 degrees of knee flexion for repeated periods of time. So they're toe tucked, they're about 25% weight bearing for two weeks, 50% weight bearing from weeks two to four, full weight bearing after four weeks off of crutches after six weeks and out of the brace somewhere around seven or eight weeks. We start some passive hip range of motion at two weeks, active hip flexion at four weeks, isotonics at six weeks and isokinetics at eight weeks, some aqua therapy and some core pelvic and closed chain exercises at ten weeks, dryland training right around three months, return to full sports participation between five and eight months. Now here's the audience participation and I think that there's a reaction key at the bottom and what I'd really just like to know is how many fellows on this call have either assisted with or helped out with a proximal hamstring repair either during the residency or their fellowship. So I think you can hit the thumbs up button and then we're going to allow our mentor to hopefully tabulate the results for us. Let's see where it shows up. Can we can we see it or no? So oh here we go. I've got some thumbs coming up here. Oh it may not calculate. It's not calculating and I'm not sure how long it's the thumbs are staying up. Come up and then the at the end it disappeared. Okay well we tried it we thought maybe we would give it a shot. That's the next you're taking me to the next level here on the complexity. So I always want to challenge you Mark because I know you're up to the task. I'm seeing about it's about look like it was about 10% maybe maybe 10 to 20% of thumbs up of with of doing doing the repairs. Good okay so you know obviously it's something that that hopefully you'll see you know during your fellowship. I will tell you that probably the most common phone call I get from colleagues and buddies are hey I'm about to do my first hamstring can you kind of walk me through the retractors and you know some things and so by all means I'm more than happy to if you don't have a colleague that you can go to for this I'm more than happy to to to run you through this at any point in time once you get out there and practice. So just kind of going into some of the epidemiology. This is a recent study out of the German group in KSSTA that was actually just published this month so I wanted to you know Mark challenges me with a talk and I want to keep them up to date as much as possible. So they looked at you know the epidemiology so males and females were fairly similar. The mechanism however was a little bit different. It was more sporting activities for males and more activities that they are living for females. The average age for this was about just under 50 years and so I will really counsel you that if you see this 45 to 60 year old age group with who has this type of injury have a high clinical suspicion because these are the ones that tear this. Again over 50 about 56% of these were between 45 and 60. Very unusual under the age of 30. I can I think I've probably done about three patients under the age of 30 or around that age group. I had one high school athlete and I've seen a couple of professional athletes and then epidemiologically they had 5% with sensory deficits in this group. So just kind of going back to some of the original and older literature again as I described in the mid 90s was when this really kind of the publication started coming out and Orava was probably one of the first and eight patients, four were acute, four were chronic. None of the chronics were able to be mobilized. They follow up, the relatively short follow-up for the minimum. All the acute repairs did well and only three quarters of the chronic tears and 75% of the chronic tears had a fair or poor result. So again just an early indication about chronic tears. Non-surgical treatment in Sally and Garrett's group, 12 patients all were water skiers, all treated non-operatively, only 58% were able to return to the prior sport at a lower level of function and then 42% of these patients were unable to return to running. Again Wood published a study in 1998, nine patients chronic hamstring rupture, again a varied follow-up. They looked at Cybex testing and found that their injured side was a 60% of their uninjured side and just less than 80% were able to return to sports. A couple more studies in the early 2000s, again out of Sally's group, 11 patients complete tears, 10 of the 11 patients achieved a satisfactory result, 91% return to strength. Imhoff's group who published that epidemiologic study, eight patients complete proximal hamstring avulsion, 88% return to pre-injury sports level and just under 90% return to strength. Jim and I published our data from in 2012 in AJSM, 52 patients. Our average follow-up was over two years, average age again very similar to what Imhoff's group published to just under 49. We looked at LEFS and MARC scores, the 80% were acute tears. Here's the mechanism of injury, sports were about you know just under half, non sports related over half, 39 of these were complete tears. We found 96% satisfied with their outcome, 76 out of 80 on their LEFS scale and 10 out of their MARC scale. Two-thirds were able to perform a very strenuous activity and all estimated that their strength was greater than 75%. And similar to what you see and we'll talk about some of the additional studies, acute repairs fare better than chronic tears. We had two DVTs in this group and I would recommend that you consider if you have somebody who's three to six weeks out from the injury, consider a preoperative ultrasound. Some patients may actually have a DVT preoperatively. I use aspirin in all patients 30 days after the surgery. We had two patients with partial tear initially treated conservatively that required surgical repair. Half had some posterior thigh numbness after surgery so it's important to counsel the patients about posterior thigh numbness and sitting discomfort. We did have one patient with a sciatic nerve palsy. Bowman shortly after published a partial thickness repair study, 17 patients who failed non-operative treatment greater than six months, majority of these were female, younger age group, follow-up was two and a half years, two collegiate athletes, 14 amateur athletes. And I will tell you that a lot of these patients have this chronic proximal hamstring tendinosis. There are females, there are runners, high mileage people that have had you know upwards of six, seven years of proximal hamstring pain. LEFS was 73 out of 80 in this group. MARC score was six and a half out of 16. All patients were able to return to their preoperative level after the surgery. Justin Arter, as I mentioned earlier, recently published the 64 patients with partial avulsions who failed non-operative treatment, a bigger extension of that 2013 study. Again, average age around 47, follow-up six and a half years. Three patients had foot numbness that resolved by six weeks. Six patients had peri-incisional numbness. I do find this to be relatively common early on. Again, three had some stitch abscess and one had a DVT. And if you look at patient satisfaction when you compare partial versus complete tears, again, complete tears you have a higher satisfaction rate, a higher return to sports rate, but you have more pain in the partial repair, partial thickness repair group. And if you look at complications, you definitely have more neurologic complications and peri- incisional numbness in the complete group. I think that those are more retraction and they definitely play a role in this. So Justin's conclusions from this study, surgical repair for patients with more than one tendon, if or if a bony avulsion is displaced greater than two centimeters, retraction less than two centimeters, treatment is individualized, and talk to the patient, and more than one tendon is torn, there's greater tension placed on the other remaining tendons, and you may consider a surgical treatment. Again, Imhoff's group looked at a recent study, again, just published in April of this year, excellent outcomes and low complication rate for proximal hamstring repair. A midterm follow-up, they had 94 patients, you know, just under five-year follow-up. Return to sports was 86 percent. Higher for acute repairs, complication rate was eight and a half percent. Again, higher in complete tears as we kind of noticed before. Partial and complete tears were similar in their outcome. This is a systematic review from out of Georgetown from 2017 AJSM. They looked at 24 studies, 795 patients, looked at operative versus non-operative treatment. Patient satisfaction was greater in the operative group, 90 versus 52 percent. Hamstring strength was greater, 85 percent versus 63 percent, and the LEFS scores were better in the operative versus the non-operative group. And I will tell you that the most common question that I get for the patient who's trying to consider whether to consider to think about the surgery, because it's a big commitment, brace for eight weeks, crutches, not sitting up, all the things, the risks of, you know, neurovascular risks. The patients always ask, well, if I don't fix it, how much weakness will I have? And this systematic review really kind of gives you a number to kind of point at. I tell them somewhere around 35 to 40 percent weakness. You know, it's kind of similar to what we talked about with distal biceps tears. You know, if you talk about what's their supination weakness that they get, 30 to 40 percent, I think if you kind of think about it that way, it gives you a good estimation and a good idea as far as what you can talk to patients about, about why they may consider fixing it. Total complications in this group, 23 percent. When you look at acute versus chronic repair, patient satisfaction, again, better in the acute tears, less pain in the acute tears, greater strength in the acute repairs, and the LEFS scores are better in the acute repairs. When you look at complete versus partial repairs, patient satisfaction, higher in the acute repair, in the, I'm sorry, in the complete repairs, less pain in the complete repairs, higher return to sport in the complete. Hamstring strength, about similar, maybe slightly higher in the partial repairs. Endurance was a little bit better in the partial repairs and definitely a higher complication rate in the complete versus partial repairs. So the conclusions from this, operatively treated patients, higher satisfaction, higher return to strength, and athletic capacity and overall functional recovery, acute repairs, better results and higher satisfaction than the chronic repairs. Partial repairs demonstrate better strength, endurance testing, and lower complication rates, but worse patient satisfaction and pain scores. The last systematic review was published at OJSM in 2019, looked at return to sport after surgery, 467 patients, 93 percent of these were complete tears, I'm sorry, 93 percent of the complete tears and 97 percent of the partial tears returned to sport after a mean of just under six months. Over 83 percent returned to the pre-injury activity level and the earlier surgery returned at a higher rate and more quickly. So again, it kind of fits the picture of acute repairs and are better than the chronic repairs. The earlier you get to them, you know, in my practice, if I can get to these within three to four weeks, I'm much happier than waiting six weeks and out to eight weeks. And generally beyond eight weeks, I have a hard time recommending surgery, particularly with significant amount of retraction, because I do think it puts them at risk. So we'll take just a second breather to go over a couple of cases on things you may or may not have seen. Well, before you go through your case, a couple of questions come up. And first one, actually before I get to Jay, you know, one of the things you talk about and Jim Bradley talks about is about, you know, if it's more than two centimeters, right? If it's less than two centimeters, it's less likely to be a two tendon tear. It's more likely to be a one tendon or less. You can treat them non-operatively. So a lot of people use this two centimeter as kind of a threshold. However, I've had three radiologists read the same MRI and he'll give me numbers between one and eight centimeters of retraction. Tips, tricks, is that your experience as well? I mean, it's amazing to me. Experienced musculoskeletal radiologists can't seem to agree on the amount of retraction. And we're putting a lot of preoperative or a lot of people put their preoperative determination or indication based on that number. Yeah, Mark, I think that's a really good point. I think that what I tend to look at is the coronal image, you know, looking at, you know, where I can see the most proximal aspect of the tendon, you know, as you can see from that, you know, the original MRI image that I showed before. You know, the axial image, difficult to look at retraction. You're really gonna have a hard time. I will say that the sagittal image can help you with that. So if you really have a hard time finding it, measure it on both of them. Measure on the sagittal, measure on the coronal. And, you know, again, you may get a different number, again, depending on the plane that you're in. But that being said, you kind of, you go by that. You know, if you have access to ultrasound, you have a really good ultrasonographer, you can certainly can think about looking at it from the ultrasound standpoint. Maybe a little bit more accurate, depending on who the radiologist is. Okay, but you also find that variability in the numbers that you have to really kind of look at it yourself and figure it out? Absolutely. And I can't tell you how many patients will send me an MRI report and it talks about retraction. I've had patients come in that have had eight centimeters of retraction on the radiology report, and I don't think they had a tear. Yeah. So, you know, this is, you know, you obviously have to have a go-to radiologist. You know, at Jefferson, we've got, you know, some of the elite guys, Adam Zoga, Bill Morrison, really, you know, elite level, Hollis Potter types that we can go to that I can really rely on. But, you know, for sure, there's variability. Yeah, and so the other thing, just for people to realize, is that the tip of the hamstring doesn't go to the tip of the ischial tuberosity. As you showed anatomically, you're bringing up higher on the lateral edge of the ischium. So when you're using your measurements to measure the distance. But that variability is just crazy. And actually, Alexander Brown wants to know, where does the two centimeter number come from? So do you want to answer that? You know, we're always taught that we shouldn't just rely on somebody who told us that. But Jim Bradley's a pretty smart guy. Obviously, the president of the AOSM now. That's kind of what it what it kind of came from. But, you know, ultimately, the idea of the two centimeters was really about kind of these high grade partial tears. And I think as we kind of discussed, and I think was mentioned in the partial tear study, you know, when you have two centimeters of retraction, if you have one tendon left, again, I think it's seeing a lot more stress. And that's where it's putting it. For a complete tear, you know, even a complete tear of one centimeter retraction, we think about the rotator cuff the same way, right? We have somebody who has a one centimeter retracted rotator cuff tear, you're not going to say, Well, I think you should leave that alone, because it's going to heal itself. So I think ultimately, you know, complete tears, even with minimal retraction, I would heavily consider repairing, but really for the two centimeter, that's more for the partial tears. Okay. Jay, you said, could you comment on the type of anchor you use? And then secondly, also the role of neuroplasty. So do you always do a sciatic nerve or identify the sciatic nerve or just kind of feel it and keep it out of the way and don't mess with it? And then which anchor are you using? So I use, you know, I've, since back in the day, I use like a three millimeter anchor. I use five of them. Again, the rationale behind a three millimeter anchor is I don't want to put a four or five. I mean, I think we're just, that real estate becomes a little bit smaller. I use absorbable anchors. I actually, you know, I'm not a, I have no affiliation to Arthrex at all, but I use a suture tack anchor that similar to what you use, what we used to use in the glenoid. I know it works well in bone. And from a standpoint, I've tried all suture anchors. The thing I don't like is having to set an anchor in the initial tuberosity when you're kind of at a little bit of a distance away. I don't like the idea of having to work with two hands while I'm setting it. I like to basically have my hand on the anchor, tap it in. Then I release the suture and pull it out, and then I can check it. The problem with those all suture anchors is you have to then sort of set it or do something to it, and I just don't want to risk the issue of having an anchor fail on me. With regard to a neuroplasty, I try to see the sciatic nerve as infrequently as possible. I basically palpate it and kind of keep an eye on where I know where it's going to be, but I don't routinely dissect it out. I don't really want to see it and put it at risk. As long as I know exactly where I am in relation to the tendon on an acute tear, then I'm fairly comfortable with palpating it and knowing I'm in a good spot. And he also asks, what's your preferred technique for a bony avulsion? Yeah, you know, that's difficult. It really depends on how, I have seen this very infrequently. If the fragment is big enough, you can use screws. If it's really just a shell, and depending on what the bed looks like, you can actually shell out the bone and then just do an anchor repair. Kind of similar to, you know, I recently had a high school athlete who had a three-month-old lesser tuberosity avulsion fracture for his, with his subscap. Again, depending on how quickly you get to it, if you can fit it in the bed, great. If not, you can shell it out and just use anchors. Okay, and then Mario Lobao, whoops, where did it go? There we go. How do you handle partial tears less than two centimeters, non-responsive to conservative treatment, biologic surgery, complete the tear and repair, in situ fixation? What's your go-to? Yeah, another good question. Again, I, you know, I think that, you know, hip arthroscopists are kind of saddled with the low back pain. You know, that's kind of what they, what comes in their office in hip pain patients. And, you know, Mark, you know this better than anybody. Sometimes, you know, that patient comes in, you know it's really not their hip. And, you know, or, you know, the knee surgeon who has, you know, Latul who gets the patellofemoral pain, and the 16-year-old female who doesn't really have any pathology, but just has patellofemoral pain. Well, when you do hamstrings, you get this, anybody with hamstring pain. So, you get the six-year proximal hamstring tendinosis. I've been a runner, you know, I run, you know, 50 miles a week. My hamstring hurts me all the time. How long have you taken off? Well, I've taken two weeks off of running, and that's the longest time period they've taken off. These are patients that get this chronic tendinosis. They get these high-grade, they develop these high-grade partial tears. Those patients I will treat nonoperatively. I will consider a PRP injection. You know, unfortunately, there's just not a lot of data out there, you know, that, that has, this has been studied. So, if you're looking for a study and have some volume out there, this would be a great study. And so, it's really hard to encourage patients to go out-of-pocket to pay for PRP. We will try corticosteroid injections. If they fail nonoperative treatment for three to six months, they've done therapy, they've taken time off of running, then I'll treat them operatively. Generally, what I'll do is kind of, again, depends on the type of tear. If it's kind of that crescent or that sickle sign that Justin described, what I'll do is basically elevate the tendon off of the ischial tuberosity from the posterior aspect. I'll roughen up the ischial tuberosity and debris it up, the tendon kind of in situ, but not taking it completely off, and then do a three-anchor repair and a triangular configuration with horizontal mattress sutures back to the location. So, I pretty much do an in situ repair. Actually, let me ask Jim Rosnick because I know he's been, you know, he's excelled from when he left his fellowship, thank goodness for him, and obviously doing lots of hamstrings these days as well. Jim, your approach on these partials, what are you doing? Yeah, I think it's very similar to what Steve described. From a non-surgical perspective, some of our, a couple of our primary care sports staff have been looking at the quality of the tendon of the ultrasound and defining whether that's more hyperemic versus more tendinotic, and then basing the role for biologics by using PRP in the more hyperemic tendons compared to the tendinotic ones using more of the percutaneous tenotomy. And if that were to fail, my technique is exactly the same as Steve described, kind of a peel down, debris the diseased tendon, and then tack it back down. So, you know, it's one of the things I've noticed since we've kind of deviated a little bit towards this chronic hamstring partial tear tendinopathy, you know, I think the paper that you did, I think you did that paper originally with Jim, right, Steve, on the, whether or not there's fluid there between versus, you know, the sickle sign versus the tendinopathy. I think what you find, and I think the reason why you look at the outcomes not being as good as the, as a complete tear, is that I think a lot of times these tendinopathy people, if you examine them, they have what's called hamstring dominance. And so when you have them lay on your belly and do that extension test that you kind of showed, if they fire their hamstring before their glute, you'll see that more often in the female athletes that have that chronic hamstring tendinopathy. If they fire their glute first, then those are the people that, you know, I'm not sure how much rehab is going to help them. But the ones that fire their hamstring before their glute, we do, we rehab the heck out of them and get them to fire their glute before their hamstring. And that usually will resolve the problem. And I think if you're operating on them and not correcting the muscle firing pattern, I think, you know, that's why I think they would still have some issues. I think it's different with the sickle people, because I think the sickle people really have a partial tear there. And I think you need to be maybe more aggressive with those. But I tend to use the biologics PRP, but it's really about the rehab for those, for the hamstring dominance. You also described talking about, Taylor, one of our therapists gave me a hand clap on that one, for your emotions there, reactions there. But the other issue for the, so for the hamstring, you don't detach the whole thing. You just kind of lift it up, clean it up for the sickle people. Is that, that's right? Yeah, exactly. Just like what Jim said, you know, you kind of elevate, you can basically enter the posterior aspect of the tuberosity. And as soon as you make that incision right in that posterior aspect of the tendon, you get an elevator in, and you actually go against the ischial tuberosity. You'll see this central defect right over where the tendon would insert. And it is, it's very dramatic. And I recently did a woman who's had, you know, eight years of hamstring pain, same thing. You know, we did one side, and she could not wait to do the other side. I mean, she was like, it was like three months. And she was like, can you do the other side now? Because she was just so happy, like, for the first time in a long period of time that she hasn't had pain. So really, they're not difficult to enter. But you do have to make sure you're dissecting right down to the ischial tuberosity. Yeah, and Carlos Guanche has a great video of it, endoscopically. I mean, that's when he started to do his hamstrings, it was just those sickle type patients. And you'll see when he cuts through the tendon, and then you get this kind of, that fluid, that kind of serosanguineous kind of fluid that comes out from there. There's just no way that that's going to end up healing on its own. Yeah. Here's another question from TLC. What DVT prophylaxis do you use postoperatively? So as I mentioned, I use aspirin for 30 days. Okay. Jim Rosnick, do you do prophylaxis, or do you do anything different? Same. I may go a little longer. It's really until they're full weight bearing, which is the same timeframe or a little longer. Okay. And I know Latul's treatment for these is to refer to you. So it's so that he tells me sending them to a hamstring specialist. Yeah, that's right. That's it. You're a hamstring specialist. Tim McAdam. I need about three minutes to do this next section, which is actually not proximal, but a different area. Okay. Real quick, Tim, do you want to comment? McAdams? No. Awesome talk. Appreciate it. Okay. All right. So we'll get, the other question was, how compliant do you think patients are with the post-op bracing and restrictions? You know, I'm pretty dogmatic about it, to be honest with you. You know, look, who knows what they do when they get home. The thing I worry about is particularly sleeping, because you really don't want them to flex up significantly. And, you know, I just think it's a protective mechanism. So, you know, it's hard to tell on compliance. I will tell you that they're probably reasonably compliant, because they all complain about it significantly when they come back to the office. So I think if they weren't compliant, they probably would say, hey, it's not that bad. All right. So let me, go ahead. You got your time for these cases. Go for it. So real quick, 23-year-old, AA outfielder. He's playing in the actual AA All-Star game, and he develops, he feels a pop in the distal posterior aspect of the thigh. Didn't really report it. And then the next day, he kind of got back and was doing some outfield drills. Felt a little bit more pain. Another case, this is a 19-year-old kid who was actually, it was our third-round pick in the June amateur draft last year. Six weeks later, he's running and feels a posterior, a pop in the distal posterior thigh medially. Both of these guys had very similar examinations, distal hamstring tenderness, weakness, and they had a bit of a deformity. And so this is kind of what you, what the appearance of it. You can kind of see medial hamstrings, a little bit of a deformity there. Here's just an example of an MRI, what you might actually see. And the diagnosis is a distal semitendinosus rupture. And I think we were going to do that, I was going to do the poll, but we don't have that. But essentially, what you see if you treat this surgically, and I'm going to talk about why you treat it surgically in a second. But basically, the distal semi-T ruptures, you have this residual stump, and it will retract over time, and it will ball up and be a significant pain limiter and cause significant discomfort. This is just another way to approach it. I kind of did it in a minimal or minimally invasive approach. And you can go ahead and try to do your thumbs up. But I wonder how many fellows had seen this, because I hadn't seen it in 12 years of practice. And then in the same summer, I saw two of them. And, you know, so what we did was we did a distal semi-T debridement from a rehab standpoint. They were full weight bearing right away until they're comfortable, general range of motion, but you want to work on knee extension, stretching, no resistive hamstring contraction for about four weeks, progressive strengthening. And these athletes actually got back, one of them got back in seven weeks, back to return to baseball after his surgery. And just to go over the literature, and I think it's really important that the fellows know this, John Conway and Dan Cooper published this in 2010. And, you know, as many of you know, John Conway is an upper extremity surgeon. But, you know, he, him and Dan, you know, published 20, looked at 25 cases over 14 years. Not very common, very elite level surgeons. They followed up on 17 cases after a year. And what they found basically was the 12 cases that were treated nonoperatively, seven returned at an average of 10 weeks. But five patients failed nonoperative treatment, went on to surgical treatment. And their total recovery time was 30 weeks. So if you treat these nonoperatively, almost half the patients, instead of being seven to 10 week return, go out to 30 weeks. And so it's a significant disability. And the average return for their acute surgical treatments was seven weeks. So they concluded that 42% failed nonoperative. And the acute surgical resection of a completely ruptured semi T actually speeds up recovery. And, you know, in an elite level athlete, it's really important that you think about doing this. So I'll let you read the summary slide. And, Mark, if there's any more questions, I'm sure I can answer. So I remember when Dan Cooper talked about that case, and there was one thumb up. But Will Workman with the A's, Will, you want to comment? Whatever, Will. I'm here. Can you hear me? Sorry. Yeah, I just mentioned, I'd never seen one. And, you know, we had one of our pitchers develop, well not develop, he had an acute hamstring, what we thought was a strain, because he had pain sort of, you know, mid posterior thigh. And we were going to maybe blow it off and not get an MRI. I'm like, ah, let's get an MRI, you know, take a look. And he had a distal rupture. And I didn't really know what to do with it, to be honest, because I hadn't seen one. And we kind of read about it. And it's like, ah, it looks like they're being debrided. He went back to Houston, I think, and had it debrided. But it was definitely an eye opener, because he did great. And I think it would have been a big miss. And I think he would have done poorly. I think you'd probably agree with that, Dr. Cohen. Yeah, Will, absolutely. You know, I had heard about these, and I probably had seen it maybe early in my career. But, you know, when you're taking care of these high-level athletes like you are, you know, it's one of those things that, you know, we scan on probably more things than we need to. But, you know, you don't want to miss it. You want to give them the opportunity to get back. Because I believe it's actually a similar thing that Hunter Pence may have had as well. Because I remember after I operated on Charlie, he said, Hunter Pence got back in seven weeks. Why am I not getting back in five months? You know, and so, you know, different issues. But I think it's definitely something you want to recognize. Steve, can you go back to the summary slide? Somebody had asked for you to do that. And in the interim, Drew Allwood asks, and I'll ask Steve and Latul and Jim Rosnick and all those cells who are around the hip and pelvis. Could you comment on the thought that anterior pelvic tilt or increased femoral anteversion puts athletes at risk for recurrent hamstring strains or chronic tendinosis? So, does anybody want to comment on that? Well, I'd have to leave that to some smarter people to answer. Because, you know, quite honestly, it's hard to know. I mean, you get these acute ruptures that come into your office. You really don't know where they were with regard to their pelvic tilt at the time. Could it have changed from the time of their injury to the time that they've seen? So, I can't necessarily answer that question as far as a risk. But maybe somebody else has a better answer. Let me see if actually, one of our physical therapists that are on, if they want to comment. I was looking to see, I don't see Gretchen here. But I don't know, Taylor or Debbie, let me unmute you guys and see if you want to, if you might want to tackle that question. I think there is some predisposition, Mark. Maybe if they're having issues chronically, that that might be a problem. But I know, like, you're a big guy about making sure that they have decent hamstring flexibility. That's one of the things that you always check with all of your athletes. So, I think that that might have something to do with it. But I agree that it's hard to tell if you're only seeing them after the fact. Taylor, do you have any, you want to add to that? Crickets. Okay. All right. Any other comments? Steve, man, that was awesome, as always. I always learn from you, listening to you. I see your son sneaking out from behind you. Actually, my daughter, who was here the whole lecture. Ah, okay. Awesome. I want to thank you for a fantastic job. I want to thank everybody for their participation. Just a reminder, tomorrow is actually, Mark Miller will be talking about revision ACL. And he's got a new name for this lecture series, which I'll leave as a teaser for tomorrow. But really appreciate Steve and everybody for participating. Y'all have a good day and stay safe. Thanks so much. Thanks, Steve. Great talk. Thanks, Mark, for inviting me. Thanks, Steve.

Multi-Institutional Sports Medicine Fellows Conference

proximal hamstring injuries

anatomy

diagnosis

surgical techniques

rehabilitation

distal hamstring injuries

partial tears

Q&A session

neuroplasty