Fortnightly we invite a colleague to share a clinical tip with our community. Today, Gustaaf Reurink is on the stage.

Who are you? 

I’m a Sports Medicine Physician and a Human Movement Scientist. I’m working at the Sports Medicine clinic in Academic hospital Amsterdam UMC and teaching hospital (OLVG Amsterdam) and at the professional football club AFC Ajax youth academy. I’m also post-doc researcher at Amsterdam UMC.

What clinical tips would you like to share with the community?

Hamstring tendon avulsions are the most severe hamstring injuries that impact sports participation and physical aspects of daily activities. Early recognition is crucial, as untreated (either conservatively or surgically) avulsion injuries may result in worse clinical outcome and long-term disability.

Many textbooks and literature are available describing the typical clinical presentation of a hamstring tendon avulsion, including a trauma mechanism involving forced hip flexion combined with knee extension and a popping sensation, severe pain, difficulty sitting, extensive bruising and a palpable gap.

Despite this, we observe in our clinical practice and research that hamstring tendon avulsions are initially often missed.¹ I suspect an important reason is that many of the injuries do not present with the described ‘typical’ signs and symptoms. Some common pitfalls are: the injury mechanism may differ (e.g. forced abduction, only low impact trauma), bruising may occur only after several days, pain can be mild, knee flexion strength may persist by m. biceps femoris short head and/or m. gastrocnemius activation and a palpable gap can be masked by extensive hematoma.

I want to share another clinical sign that, in my experience, raises a high suspicion of a hamstring tendon avulsion, even in absence of the ‘typical’ symptoms: an inability to activate the hamstring muscles and loss of hamstring proprioception.

• During history taking, ask for signs for loss of balance, coordinative and/or proprioceptive function: loss of subjective control of the leg, difficulties in (one leg) balance tasks, stumbling/tripping, patients indicating ‘their leg feels different’
• Clinical examination (see videos):
  1. One leg balance test (closed eyes for increased difficulty): look for insufficiencies, compare with to contralateral leg (video 1),
  2. Hamstring recruitment during isometric knee flexion resistance test in prone position. Look and feel for hamstring contraction: no contraction or a marked loss of muscle tone are suspect for avulsion injury (video 2).

I advocate that in the presence of this sign referral for diagnostic imaging (e.g. MRI) is indicated to either confirm or exclude the diagnosis, as it has direct consequences for treatment and prognosis.

BOSEM clinical tip_Reurink_video 1

BOSEM clinical tip_Reurink_video 2

Where does it come from?

This is my personal clinical experience in the many patients with hamstring (avulsion) injuries I have seen in both our hamstring research projects as well as in clinical practice.

What is its scientific evidence, if any?

There is no scientific evidence in the literature. This is pure expert opinion.

Reference

Anne D van der Made, Johannes L Tol, Gustaaf Reurink , Rolf W Peters, Gino M Kerkhoffs. Potential hamstring injury blind spot: we need to raise awareness of proximal hamstring tendon avulsion injuries. Br J Sports Med 2019 Apr;53(7):390-392.