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Proximal Hamstring Syndrome in Athletes

In this report from Australia, the results of surgical treatment for proximal hamstring syndrome are discussed. The sciatic nerve is released from the hamstring muscle where the two have become tethered or attached by adhesions or scar tissue. Proximal refers to the upper portion of the hamstring muscle where it attaches to the ischial tuberosity (the part of the pelvic bone that we sit on).

The hamstring syndrome was first discussed in the late 1980s. Athletes involved in many different types of sports have experienced the pain, tenderness, and weakness that occur with this syndrome. At first it was only called hamstring syndrome. But the current authors have renamed it proximal hamstring syndrome to indicate a more precise location of the problem.

The condition must be differentiated from several other possible causes of buttock and leg pain (e.g., sciatica, piriformis syndrome, hamstring muscle tear). The surgeon takes a careful history and performs an exam to make the diagnosis. The patient may report a specific (hamstring) injury that led to the start of this problem. Or the symptoms may have developed slowly over time creating a chronic problem of hamstring tears with scarring and eventual tethering.

Usually, the pain pattern of proximal muscle syndrome is slightly different from these other conditions. There is pain in the buttock that goes down the leg toward the back of the knee. When the examiner presses on the ischial tuberosity, it reproduces the pain or is tender.

Sitting or stretching the hamstrings also brings on the painful symptoms. This pattern is different from a hamstring tear where the pain is more in the muscle belly or the piriformis syndrome where the tenderness is deep in the buttock muscles. Weakness of the hamstring muscle is also common with proximal hamstring syndrome. The athlete is unable to run at full speed -- or even increase the pace in that direction.

Nerve conduction tests were not always helpful. The results were just as likely to be positive or negative in patients with proximal hamstring syndrome. A better test was performed with the patients prone (face down). Strength of the hamstring muscle was tested with the knee bent to 30 degrees and compared with the same strength test at 90 degrees. Severe weakness with the knee flexed at 30 degrees (compared with normal strength at 90 degrees) was a good test for this problem.

The authors developed a surgical protocol for these patients. The senior author spent 10 years reviewing patient records. He looked back at the presenting symptoms, what treatment worked the best, and the results of this surgery. Patients involved were all ages from 15 to 58. They were all involved in competitive sports, some even professionally.

Everyone was treated first with conservative (nonoperative) care. Treatment varied from patient to patient but included nonsteroidal antiinflammatory medications, steroid injections, chiropractic, physical therapy, and/or acupuncture. When the thigh pain and weakness did not improve, then surgery was indicated.

The authors described the surgery performed. Patient position, surgical technique, and ways to prevent complications are discussed. The sciatic nerve was carefully cut away from the hamstrings. Scar tissue and any areas of obvious tendon scarring or degeneration were removed.

Follow-up included a short rehab program to restore motion and strength. Patients were interviewed by questionnaire during the subsequent follow-up. They were asked about pain, strength, return-to-sports, and satisfaction with the results.

Pain relief was reported by most (but not all) patients. Strength improved to normal or near normal in 25 of the total 35 patients. The remaining 10 had no change or reported increased weakness. Three-fourths of the patients were able to return to competitive sports action.

Pain and weakness prevented three players from returning to the sport of their choice. The patients who were able to return to sports participation were very satisfied with the results of the surgery. One-third of the group was perfectly satisfied, giving top scores on the survey to indicate their response to the outcomes.

The authors conclude that proximal hamstring syndrome that does not respond well to conservative care can be effectively treated surgically. At least six months of nonoperative care is advised before considering surgery. Severe pain and weakness that interfere with function are the main reasons patients choose surgery.

The authors also warned that surgeons must approach this problem carefully. It's easy to misdiagnose. Surgical treatment can result in complications such as wound infection or nerve injury. The sciatic nerve must be released very carefully. The nearby posterior femoral cutaneous nerve must not be disturbed or traumatized in any way. Patients must be prepared ahead of time for the possibility of a poor or failed result.

References: Ian J. Young, BSc, MD, CCFP, FRACGP, FRACS, et al. Surgical Release for Proximal Hamstring Syndrome. In The American Journal of Sports Medicine. December 2008. Vol. 36. No. 12. Pp. 2372-2378.

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