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Functional Outcome After Repair of Proximal Hamstring Avulsions
Patrick Birmingham, MD1; Mark Muller, MD2; Thomas Wickiewicz, MD3; John Cavanaugh, PT, MEd, ATC3; Scott Rodeo, MD3; Russell Warren, MD3
1 Department of Orthopaedic Surgery, Medical College of Wisconsin, 9200 West Wisconsin Avenue, P.O. Box 26099, Milwaukee, WI 53226. E-mail address: patrickbirmingham@gmail.edu
2 Carrell Clinic, 9301 North Central Expressway, Suite 400, Dallas, TX 75231-5009. E-mail address: mmuller@wbcarrellclinic.com
3 Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021. E-mail address for T. Wickiewicz: WickiewiczT@hss.edu. E-mail address for J. Cavanaugh: CavanaughJ@hss.edu. E-mail address for S. Rodeo: rodeos@hss.edu. E-mail address for R. Warren: warrenr@hss.edu
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Disclosure: None of the authors received payments or services, either directly or indirectly (i.e., via his or her institution), from a third party in support of any aspect of this work. One or more of the authors, or his or her institution, has had a financial relationship, in the thirty-six months prior to submission of this work, with an entity in the biomedical arena that could be perceived to influence or have the potential to influence what is written in this work. No author has had any other relationships, or has engaged in any other activities, that could be perceived to influence or have the potential to influence what is written in this work. The complete Disclosures of Potential Conflicts of Interest submitted by authors are always provided with the online version of the article.

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Investigation performed at the Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, NY

Copyright © 2011 by The Journal of Bone and Joint Surgery, Inc.
J Bone Joint Surg Am, 2011 Oct 05;93(19):1819-1826. doi: 10.2106/JBJS.J.01372
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Rupture of the proximal origin of the hamstrings leads to pain, weakness, and a debilitating decrease in physical activity. Repair of these injuries should be based on the expectation that these deficits can be addressed. The goal of this study was to objectively evaluate the efficacy of repair of proximal hamstring avulsions.


Thirty-four patients were identified retrospectively to have a complete rupture of the proximal origin of the hamstrings based on the presence of a bowstring sign and the results of magnetic resonance imaging (MRI).Patients were contacted for follow-up evaluation to fill out a subjective questionnaire, to undergo functional testing, and to undergo isokinetic testing on a Cybex dynamometer. Twenty-three patients were evaluated.


There were nine acute and fourteen chronic repairs, and the average period of follow-up was 43.3 months. Twenty-one of twenty-three patients reported returning to activity at an average of 95% of their pre-injury activity level at an average of 9.8 months. Eighteen patients reported excellent results; four, good results; and one, fair results. Hamstring strength was an average of 93% and 90% of that in the uninvolved limb at 240° per second and 180° per second, respectively. The hamstrings-to-quadriceps ratio was 56% for 240° per second and 48% at 180° per second. Hamstring endurance was an average of 81% and 91% of the nonoperative limb at 240° per second and 180° per second, respectively. Postoperative quadriceps strength and endurance were positively correlated with return to pre-injury level of activity (r = 0.6, p < 0.05; and r = 0.6, p < 0.05) and negatively correlated with time to return to sport (r = –0.5, p < 0.05; and r = –0.5, p < 0.05). There was no significant effect associated with age or time from injury.


Repair of a symptomatic and displaced ruptured proximal hamstring tendon yields good subjective and objective functional results with minimal complications. Overall, patients are satisfied with surgical repair and experience return of functional activity with minimal postoperative weakness.

Level of Evidence: 

Therapeutic Level IV. See Instructions to Authors for a complete description of levels of evidence.

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    These activities have been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint sponsorship of the American Academy of Orthopaedic Surgeons and The Journal of Bone and Joint Surgery, Inc. The American Academy of Orthopaedic Surgeons is accredited by the ACCME to provide continuing medical education for physicians.
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