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I tore the hamstring muscle in my left leg (up by the buttocks). It's been six months and it's not getting any better. I'm stiff. It hurts, and I have limited motion. Have I waited too long to have surgery?

Probably not -- at least according to a recent study done at the Hospital for Special Surgery in New York City. The orthopedic surgeons there compared 23 cases of acute and chronic proximal hamstring rupture. Proximal refers to the place where the muscle attaches at the top. For the hamstrings, the proximal muscle attachment is to the ischial tuberosities -- the bump of bone you feel in your buttocks when sitting down. There are three separate tendons that meld together at this site. For a complete rupture, all three tendons are torn. The rip or tear could be anywhere along the muscle but this study focuses on tears at the ischial tuberosities. If it's the tendon that is torn and the attachment is pulled away from the bone, it's called an avulsion. Chronic injuries (those that occurred more than a month ago) that are asymptomatic (no symptoms, no pain) can be treated conservatively (without surgery). But for patients like yourself with significant symptoms who don't seem to recover, surgery may be indicated. The surgeon also relies on the bowstring sign and MRI findings to make the diagnosis and determine the severity of the problem. A positive bowstring sign (indicating full rupture of the hamstrings) occurs when the examiner presses on the back of the knee just above the joint. There should be a cord of tendon that is easily felt on either side of the knee back there. But with a proximal rupture, the tension on the hamstring muscle is less so those tendons don't tense up or form a palpable cord. A positive bowstring sign is one indicator that surgery is needed. But to make sure that following these guidelines really provides the intended results, these surgeons followed their 23 cases for at least one full year (and up to nine years in some participants) to see what kind of results they got. Tests were done to measure muscle strength and endurance. Level of return to activity was reported along with any symptoms (pain, weakness, numbness, stiffness). One-third of the group had acute injuries repaired surgically within four weeks after the trauma. The remaining two-thirds were considered chronic because the injury occurred more than a month before the surgery was done. The researchers looked to see if age (patients ranged in age from 19 to 65 years old), sex (male versus female), and time-to-surgery (acute versus chronic) made a difference in the final results. The majority of patients (18 of the 23) had an excellent result with full return to their preinjury level of activity, including sports participation. Five patients never had that full (100 per cent) assurance that they could engage in all activities normally. Those same 18 patients with excellent results had no symptoms of pain, stiffness, or numbness. Their strength was measured as equal to or better when compared with the other (uninjured) leg. Those patients who achieved full return of hamstring strength and endurance got back normal faster. Larger hamstring tears seemed to lag in endurance but not necessarily strength. Age was not a significant factor. The authors of this study suggest that larger tears observed in patients with a positive bowstring sign may be the best candidates for surgery. In other words, the degree of displacement or retraction of the ruptured tendon is a reliable factor in pointing to the need for surgery. Chronic injuries can and do heal and patients recover fully.


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