Opinion

LESS IS MORE
PERSPECTIVE

Michael J. Barry, MD
John D. Stoeckle
Center for Primary Care
Innovation, General
Medicine Division,
Massachusetts General
Hospital, Boston.
William E. Palmer, MD
Department of
Radiology,
Massachusetts General
Hospital, Boston.
Alex J. Petruska, PT,
SCS, LAT
The Sports Physical
Therapy Service,
Massachusetts General
Hospital, Boston.

Editor's Note page 17

Corresponding
Author: Michael J.
Barry, MD, General
Medicine Division, John
D. Stoeckle Center for
Primary Care
Innovation,
Massachusetts General
Hospital, 50 Staniford
St, Eighth Floor,
Boston, MA 02114
(mbarry@partners.org).
jamainternalmedicine.com

A Proximal Hamstring InjuryGetting Off

a Slippery Slope
On a hot July night in 2011, at age 58 years, I (M.J.B.)
lunged for a perfectly hit tennis ball and felt sudden, severe pain in the back of my right thigh. I immediately collapsed and landed in a plume of red clay. Over the next
few days, I was able to bear weight with the help of a
cane, though I noticed numbness and impressive bruising down the back of my right leg. Obviously, I had injured my hamstring muscles and likely the posterior
cutaneous femoral nerve as well. Being inherently conservative and wanting to avoid overmedicalization,
I called my primary care physician, who referred me for
a physical therapy consultation.
My physical therapist did a thorough assessment and
was alarmed by my persistent pain and lack of strength
when he performed a manual muscle test for knee flexion. He was concerned enough to be reluctant to begin
therapy until there was some further evaluation.
I underwent magnetic resonance imaging (MRI) 9
days after the injury. The images looked ugly (Figure).
The scan showed a complete avulsion of the conjoint tendon of the semitendinosis and biceps femoris from the
ischial tuberosity, with about 3 cm of retraction. The
semimembranosis tendon was partially torn at its insertion as well. The muscles were edematous with fluid
tracking along the fascial planes of the posterior compartment. With such a fragile residual attachment, my
therapist did not want to initiate an exercise program.
After viewing my own MRI, the dramatic findings
suggested the need for surgery to reattach the conjoint tendon, so I made an appointment with a senior orthopedic trauma surgeon. My review of the literature
seemed to agree with my conclusions. I found a systematic review1 of the treatment of proximal hamstring injuries, published earlier that year. The abstracts bottom line: Non-operative treatment results in reduced
patient satisfaction, with significantly lower rates of return to pre-injury level of sport and reduced hamstring
muscle strength.1(p490) But the full text raised reasons
to be concerned about the conclusion. There were no
randomized clinical trials of operative vs nonoperative
treatment. Eighteen cohort studies were included with
298 subjects and 300 injuries. My heart went out to the
two unfortunates with bilateral injuries. Two patients
were injured while bull-riding, making me feel my tennis injury was a bit pedestrian. Of most concern, the 18
studies described the outcomes of 286 injuries treated
operatively, and only 14 treated nonoperatively. Three
studies included 1, 3, and 10 nonsurgical cases. In the cohort study with 10 cases,2 12 patients with partial or complete avulsions, all sustained while waterskiing, were initially treated nonoperatively. Seven patients eventually

returned to their preinjury sports, and 5, all of whom had

complete avulsions, did not, including 2 who underwent delayed repairs. Still, I was swayed by the conclusions and what seemed to be a consensus in the literature regarding repair for more severe avulsion injuries,
even though, again, it ran against my less is more mindset (I once told a dentist who gave me a survey about my
dental goals that my aim was not to be buried with anything too expensive).
When I had my orthopedics consultation, I was first
seen by a resident, who looked at my MRI scan and immediately began to discuss possible dates for surgery.
The senior orthopedist, however, indicated that in his experience, such injuries usually healed well with time and
conservative therapy as long as there was even a little
residual attachment. He told me he repaired such injuries only in extremely high-level athletes, a quote now
immortalized in my medical record. My initial reaction
included both surprise and relief. But soon, I was struck
that his experience encompassed far more cases of conservative treatment than the sum total represented in
the medical literature. In a health care environment with
a predilection for intervention, good data on the natural history of disease treated conservatively can be hard
to come by. I have certainly found that to be the case in
the area of prostate diseases, one of the subjects of my
own research, where reporting on its usually indolent nature provided support for conservative treatment in
many cases.3,4 In preparing this article, my coauthors and
I were interested to find another recent case series5 of
17 patients with complete avulsions of all 3 hamstring
tendons, 12 of whom returned to sport without surgery
despite a reduction in strength on the affected side.
I returned to physical therapy with the orthopedists blessing, and slowly but surely, my pain
decreased and my strength and even my sensation
returned. By September, my knee flexion strength on
the right with a handheld dynamometer had increased
to about 60% of that on the left, and by November, it
reached 80%, the threshold my therapist had set for a
return to running. After 2 more months of gradually
increasing running and cutting exercises, and with a
new appreciation for the value of stretching, I was
able to return to tennis in January 2012. I might have
returned to the courts a little earlier, I suppose, with
surgery, but who can be sure? I was fortunate that I had
access to excellent specialty care and that my injury
affected my pastime; I can only imagine how difficult
navigating this decision might be for the patient without these resources or whose injury might instead
affect his or her livelihood.

(Reprinted) JAMA Internal Medicine January 2016 Volume 176, Number 1

Copyright 2016 American Medical Association. All rights reserved.

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15

Opinion Perspective

Figure. Fluid-Sensitive Magnetic Resonance Imaging Scans

A Image of the thigh

Image of the thigh

A, The image of the thigh shows that the conjoint semitendinosis-biceps

femoris tendon (arrowhead) is ruptured, retracted from ischial tuberosity, and
surrounded by hemorrhage. B, The image of the thigh shows edema of

semitendinosis and biceps femoris muscles (arrowheads) and hemorrhage in

surrounding fascial planes. F indicates femur.

Our request to clinicians who have experience with the natural history of disease: report it. Natural history studies describing
the outcomes for cohorts of patients recruited consecutively and
treated conservatively, comparative effectiveness studies, and
randomized clinical trials can all be helpful. Methodologically
sound reports of conservative treatment are important to pub-

lish. The bodys remarkable healing power in many circumstances

deserves documentation, and can be even more informative and
educational than the results of cutting edge interventions. The
information may help someone else get off a slippery slope
safely and with a good outcome such as in the case described
herein.

Published Online: November 30, 2015.

doi:10.1001/jamainternmed.2015.6795.
Conflict of Interest Disclosures: None reported.
Additional Contributions: We would like to thank
Suzanne J. Koven, MD, General Medicine Division,
Massachusetts General Hospital, who provided
helpful comments on an earlier draft of the
manuscript. She was not compensated for her
contributions.
1. Harris JD, Griesser MJ, Best TM, Ellis TJ.
Treatment of proximal hamstring ruptures a systematic review. Int J Sports Med. 2011;32(7):
490-495.

16

2. Sallay PI, Friedman RL, Coogan PG, Garrett WE.

Hamstring muscle injuries among water skiiers.
Functional outcome and prevention. Am J Sports
Med. 1996;24(2):130-136.
3. Barry MJ, Fowler FJ Jr, Bin L, Pitts JC III, Harris
CJ, Mulley AG Jr. The natural history of patients
with benign prostatic hyperplasia as diagnosed by
North American urologists. J Urol. 1997;157(1):10-14.

5. Hofmann KJ, Paggi A, Connors D, Miller SL.

Complete avulsion of the proximal hamstring
insertion: functional outcomes after nonsurgical
treatment. J Bone Joint Surg Am. 2014;96(12):10221025.

4. Lu-Yao GL, Albertsen PC, Moore DF, et al.

Outcomes of localized prostate cancer following
conservative management. JAMA. 2009;302(11):
1202-1209.

JAMA Internal Medicine January 2016 Volume 176, Number 1 (Reprinted)

Copyright 2016 American Medical Association. All rights reserved.

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