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The American Journal of Sports

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Timing of Surgery for Complete Proximal Hamstring Avulsion Injuries: Successful Clinical Outcomes
at 6 Weeks, 6 Months, and After 6 Months of Injury
Raj Subbu, Harry Benjamin-Laing and Fares Haddad Am J Sports Med 2015 43: 385 originally published online
November 17, 2014 DOI: 10.1177/0363546514557938

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Timing of Surgery for Complete
Proximal Hamstring Avulsion Injuries
Successful Clinical Outcomes at 6 Weeks, 6
Months, and After 6 Months of Injury
y y
Raj Subbu,* MBBch, MRCS, Harry Benjamin-Laing, MBBS, MRCS,
y
and Fares Haddad, BSc, MCh(Orth), FRCS(Orth), FRCS(Ed), Dip.Sports Med,
FFSEM Investigation performed at the Institute of Sport Exercise and Health,
University College London Hospitals, London, UK

Background: Avulsion of the proximal hamstring origin is well documented, and surgical treatment is advocated for complete
avulsions.
Purpose: To compare the return to preinjury level of sport and the complexity of surgery in athletes undergoing surgical interven-
tion for complete proximal hamstring avulsions within 6 weeks, 6 months, and after 6 months of injury.
Study Design: Case series; Level of evidence, 4.
Methods: This was the largest case series from a tertiary referral center reported in the literature. A total of 112 athletes were
included, with complete proximal avulsion injuries confirmed on MRI scans; 63 patients (56.3%) were high-level athletes.
Patients were divided into subgroups depending on the timing of surgical intervention: ‘‘early’’ was defined within 6 weeks,
‘‘delayed’’ within 6 weeks to 6 months, and ‘‘late’’ after 6 months. All patients were surgically explored and repaired with the aim
of com-paring the timing between each group and the return to preinjury sport. All patients underwent an individualized
rehabilitation pro-tocol. There was no loss to follow-up. The primary outcome measure was the return to preinjury level sports
activity.
Results: A total of 108 patients (96.4%) returned to sport. In the early intervention group, the average time of return to play was
16 weeks, 9 weeks faster than the delayed group and 13 weeks faster than the late group. There were 2 partial reruptures in
those with delayed intervention—both athletes retired from competitive sport but were recreationally active. Two other athletes
recov-ered well but retired from playing at all levels. Twelve athletes (2 in the early intervention group, 5 in the delayed, 5 in the
late) were delayed by local nerve symptoms. Only 2 cases required further exploration.
Conclusion: Early surgical intervention was associated with good clinical outcomes and a quicker return to sport; however,
delaying the diagnosis can lead to prolonged morbidity and an increased likelihood of complications.
Keywords: complete proximal hamstring avulsion; timing of surgical repair, return to sport

Hamstring muscle belly and musculotendinous injuries are a due to a better understanding of the mechanism of injury and the
common sporting injury,12 but avulsions of the proximal hamstring anatomy of the ischial region, along with improved imaging
complex are increasingly being recognized. This is because modalities.
patients are becoming more engaged in sporting activities and we The proximal hamstring complex is frequently injured in
are accurately diagnosing these injuries athletes26 with the prevalence of complete ruptures reported as 9%
of all hamstring injuries.20 Complete rup-
*Address correspondence to Raj Subbu, MBBch, MRCS, Institute of Sport ture of the proximal complex has been defined as the tear-ing of all
Exercise and Health, University College London Hospitals, 170 Tot-tenham 3 tendons with or without retraction.8,29 The knee
Court Road, London, UK, W1T 7HA (e-mail: rajsubbu1 @hotmail.com). and hip joints are stabilized by the hamstring muscles due to
y eccentric contractions, which occur when a muscle con-tracts
Institute of Sport Exercise and Health, University College London
Hospitals, London, UK.
while passively stretched. This happens to the ham-string muscle
The authors declared that they have no conflicts of interest in the
during forced flexion of the hip with the knee extended. Injuries to
authorship and publication of this contribution. the muscle and proximal complex are much more common during
eccentric contractions.13 Patients may have a history of acute pain
The American Journal of Sports Medicine, Vol. 43, No. 2 at the buttock crease, an antalgic gait, loss of hip function, and
DOI: 10.1177/0363546514557938
2014 The Author(s) reduced

385
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386 Subbu et al The American Journal of Sports Medicine

hamstring power. Physical examination often reveals swelling and this muscle having the highest frequency of tears. 5 The function of
massive ecchymosis in the posterior aspect of the thigh, which may the semimembranosus and semitendinosus is to extend the hip, flex
even track distally. There may also be a positive bowstring sign the knee, and also rotate the tibia medially, especially when the
when the patient is assessed in the prone position with a palpable knee is flexed. The function of the biceps femoris is to flex the
lack of ten-sion on passive flexion of the knee to 90L. 15 Palpation knee and rotate the tibia laterally. The long head of the biceps
at the gluteal crease evokes tenderness, and there is reduced power femoris also aids in extending the hip. Anatomic studies have
in both flexion of the knee and extension of the hip. Tenderness shown variations in proximal hamstring anatomy in relation to the
proximally should alert the clinician to the possibility of an origin at
avulsion. Once the patient is clinically assessed, radiological the ischial tuberosity, tendon structure, and the path of the sciatic
imaging is required for confirmation of the diagnosis. Magnetic nerve1,14,24,27 and should be considered when inter-
resonance imaging (MRI) and ultrasonography (US) remain the preting radiological images and surgical planning.
imaging modalities of choice. 20 With greater severity of injury The purpose of this study was to compare the surgical
there is a great amount of hemorrhage, edema, and fluid involving outcomes and return to play of patients undergoing opera-tive
a larger longitudinal and cross-sectional area. 20 Studies have com- intervention within 6 weeks, 6 months, and after 6 months of a
pared MRI and US to measure these indications and have shown complete avulsion injury. This was the largest case series reported
MRI to consistently demonstrate large areas of edema and greater in the literature regarding the timing of surgical intervention and
sensitivity in picking up subtle fluid changes, anatomic location, return to preinjury level of sport.
and defining an injury classification.9,29

MATERIALS AND METHODS


Avulsions of the proximal hamstring are well recog-
nized in athletes participating in dancing, judo, bull riding, and The Institute of Sport Exercise and Health is a national tertiary
waterskiing.2,6,10,22 They are increasingly being reported in soccer referral center, with all pelvic and associated avul-sion injuries
and rugby players.3,28,30 Traditionally recorded into a national database. This was a prospective, single-
these avulsions have been treated nonoperatively or surgically. surgeon series occurring between 2002 and 2010. Informed
consent was obtained from all athletes included. The senior author
(F.H.) performed the surgical exploration and repair of complete
avulsions of the proximal hamstring complex. Before surgery, all
PROXIMAL HAMSTRING ANATOMY those included had bilateral MRI scans to confirm the diagnosis
and assess any individual anatomic variances.
The hamstring complex consists of 3 muscles: biceps femo-ris,
semimembranosus, and semitendinosus. The adductor magnus Athletes were divided into elite-level athletes and ‘‘weekend
muscle has a tendinous slip originating from the inferomedial warriors.’’ Elite-level athletes were defined as those who were
aspect of the ischial tuberosity and is some-times referred to as the regularly active at a professional or semi-professional level;
hamstring component,21 but the general consensus is to view the weekend warriors were defined as those physically active for
hamstring complex as the 3 muscles stated above. Proximally the recreational purposes. ‘‘Early inter-vention’’ was defined as that
semimembra-nosus originates on the superolateral aspect of the which allowed intervention within 6 weeks of injury, ‘‘delayed’’
ischial tuberosity beneath the proximal half of semitendinosus, the was defined as inter-vention occurring between 6 weeks and 6
innervation of both semimembranosus and semitendi-nosus is from months, and ‘‘late’’ was defined as intervention occurring more
the tibial nerve. The semitendinosus is a sin-gle muscle arising than 6 months after injury. Our data represented a collation of the
from the inferomedial aspect of the ischial tuberosity. It is thought operatively managed complete avulsion injuries that have a
to form a conjoint tendon with the long head of biceps femoris. minimum 2-year follow-up, with the principal out-come of
The great length of this muscle has been thought to predispose it to comparing the timing of surgery and return to preinjury-level
rupture.20 The biceps femoris is considered as a double muscle, sports between each group. Statistical anal-ysis was performed
hav-ing a long and short head. The long head arises from the between each subgroup and the time of return to play using simple
medial facet of the ischial tuberosity and the short head from the linear regression. In addition, further statistical analysis comparing
lateral supracondylar ridge of the linea aspera of the femur. The the amount of retraction of the proximal hamstring complex
short head is the only part of the ham-string complex not to span 2 between each group was carried out using the Kruskal-Wallis test.
joints and has not been consid-ered as a true hamstring muscle.
The origin of the biceps on the femur has been used as a landmark
to distinguish between proximal and distal injuries 11 and both the All patients were followed up until return to play was
proxi-mal distal tendons span the entire length of the muscle. There established; there was no loss to follow-up. Follow-up was
is dual innervation with the long head innervated by the tibial and obtained in a number of ways. The majority of the patients were
the short by the peroneal nerve. This may lead to asynchrony in seen directly for review by 1 of the allocated nursing or physical
coordination and intensity of stimulation and has been put forward therapy teams. Where that was not possible, the same metrics were
as a reason for obtained by telephone or e-mail dis-cussion with the therapist.

Only patients with complete avulsions, with any amount of


retraction, who underwent surgical intervention

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Vol. 43, No. 2, 2015 Surgical Management of Complete Proximal Hamstring Avulsions 387

Figure 1. Massive bruising in the gluteal and posterior thigh.

were included. The decision for surgery was made follow-ing a


multidisciplinary approach, and discussion with the patient and
teams including the risks and benefits of all other treatment options Figure 2. Transverse incision in the gluteal crease.
was performed. Surgical indica-tions included pain, weakness,
hamstring dysfunction, pre-vious hamstring injuries, and previous
Once the tendon ends were found and mobilized, there was no
hamstring harvest for anterior cruciate ligament (ACL)
difficulty bringing them back up any time to 6 months after injury.
reconstructions.
Particular care is required to preserve the sciatic nerve branches to
We used a structured rehabilitation program that cen-tered the hamstring muscles, but otherwise it is relatively
around using the first 4 weeks as healing time while protecting the straightforward once the sciatic nerve has been mobilized to
patients, the next 4 weeks to regain range of motion and regain mobilize the tendon and bring it back up to position. In this series
function, and then a graduated return to sport-specific activity.
we did not need to aug-ment any tendons with allograft or mesh, as
Each patient was given an indi-vidualized rehabilitation program.
others occa-sionally have described.23 We perhaps dissected more
and accepted deep flexion in chronic cases; the decision to apply a
brace was made intraoperatively depending on the amount of
Surgical Techniques tension that was placed on the surgical repair. The brace was set
with the knee flexed at 90L for up to 6 weeks to protect that repair,
All procedures were performed under a general anesthetic. The and we have found this technique to be successful without needing
surgical techniques involved the patient in the prone position. The allografts. The number of large-bone suture anchors required
typical incision was made in the buttock crease, except in the varied depending on the size of the patient. The type of anchor
chronic cases beyond 6 months where considerable retraction and used was a Healix anchor (Mitek). We used 2 for a small female
scarring was expected and a vertical incision is used. We did not and 3 or 4 for a large male patient. The suture anchors have a metal
find it necessary to convert from a buttock crease to a vertical peg, which is fastened into the ischial tuberosity. The synthetic
incision other-wise, although patients provided consent for this. sutures attached to the metal peg were then passed through the
After meticulous preparation and draping of the surgical site, a mobilized tendon to fashion a well-tensioned bone-tendon
horizontal skin incision was made along the gluteal crease. approximation. Figures 1 to 6 illustrate the clinical presentation
and highlight the sur-gical procedure.

Once the incision was made and hemostasis was obtained with
diathermy, the gluteus maximus was retracted superiorly to protect
the inferior gluteal neuro-vascular bundle, which lies proximal to
the incision site (approximately 5 cm proximal to the inferior
border of the gluteus maximus muscle), and allow access to the RESULTS
ham-string complex. The posterior cutaneous nerve of the thigh
was identified and protected. The hamstring injury was then A total of 112 athletes with complete proximal hamstring avulsion
identified. This was straightforward in the early inju-ries by the injuries were identified and surgically explored. The average age
hematoma created by the injury and allows a safe zone for repair was 29 6 8.5 years (range, 18-52 years); all patients were skeletally
with the sciatic nerve not stuck down within the hematoma, mature. There were 76 male and 36 female patients, and 63 of
however it proved very diffi-cult with the late and delayed groups, these were elite-level ath-letes. The most common sports
where the tendons had to be dissected away meticulously from the implicated in these injuries were rugby (27.7%) and soccer (17%).
scar tissue and were more difficult to identify. It was critical in Previous injuries to participants included 17 hamstring muscle
every case to identify and protect the sciatic nerve, which was substance inju-ries, 2 contralateral proximal avulsions, and 2 ACL
extremely stuck down even at 6 to 8 weeks after surgery. recon-structions using ipsilateral hamstring grafts; 19% of all
patients had suffered previous injuries. Demographics for

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388 Subbu et al The American Journal of Sports Medicine

Figure 3. (A) The proximal complex is identified. (B) This is further secured and prepared for re-attachment.

Figure 4. (A) The proximal complex is mobilized and brought proximally toward the ischial tuberosity. (B, C) This is re-attached
into the ischial tuberosity successfully with sutures and anchors as described in the text.

Figure 6. (A) Sciatic nerve identified and mobilized. (B) The


posterior cutaneous nerve of the thigh was protected.
Figure 5. In more chronic cases, a longer longitudinal inci-
sion was required because of greater retraction and pre-
dicted neurolysis. an earlier return to play, regardless of the type of sport, in the early
intervention group compared with the delayed and late groups.

each group are summarized in Table 1, and average return to play In the early group, the mean time to surgery from injury was 22
for each sport is given in Table 2. Results indicated days (range, 5-42 days). In the delayed group it was

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Vol. 43, No. 2, 2015 Surgical Management of Complete Proximal Hamstring Avulsions 389

TABLE 1
Patient Demographics

Early Intervention (\6 wk) Delayed Intervention (6 wk to 6 mo) Late Intervention (.6 mo)
Age, y, mean (range) 29.7(18-52) 28.6(18-54) 30.7(19-40)
Sex, male:female, n 51:27 18:6 7:3
Retraction, cm, mean (range) 4(1-9) 4.4(0.5-8) 5.1(3-11)
No. of athletes (elite-level) 78(56) 24(7) 10(0)

TABLE 2
Average Return to Play in Each Individual Sport

Early Intervention (\6 wk) Delayed Intervention (6 wk to 6 mo) Late Intervention (.6 mo)
Athletes, n Average Return Athletes, n Average Return to Athletes, n Average Return to
Sport (elite level) to Play, wk (elite level) (elite level) Play, wk (elite level) (elite level) Play, wk (elite level)

Soccer 17 (14) 15 (14) 3 (3) (25) 1 (0) 29


Rugby 32 (26) 15 (14) 6 (2) 21 (29) 2 (0) 34.5
Waterskiing 8 (1) 20 (15) 5 (0) 28 2 (0) 37.5
Skiing 4 (2) 24 (13) 1 (0) 40 2 (0) 26
Lacrosse 2 (2) (13.5) 1 (0) 24
Martial arts 3 (3) (14) 1 (0) 28
Running 3 (3) (16)
Netball 2 (1) 15.5 (14) 1 (1) (27)
Hockey 1 (1) (19) 2 (0) 23.5
Gymnastics 2 (2) (21)
Equestrian 2 (0) 25.5
Ultimate Frisbee 2 (0) 22
Cricket 1 (1) (21) 1 (0) 26
Tennis 1 (0) 20
Hurdles 1 (1) (18)
Dance 1 (0) (13)
Skydiving 1 (0) 24
Horse racing 1 (0) 27

84 days (range, 43-182 days), and in the late group the mean was delayed group, and 5.1 6 3 cm (range, 5.10-11 cm) in the late
357 days (range, 183-512 days). group. Comparison of means showed no significant statistical
There were 108 patients (96.4%) who returned to the same difference between early versus late (P = .28), early versus delayed
level sport, at an average of 19 weeks (range, 12-32 weeks). The (P = .38), and delayed versus late (P = .51) groups. The Kruskal-
average return to activity in the early group was 16 weeks (range, Wallis test showed no signif-icant variance in the amount of
12-32 weeks), 25 weeks (range, 18-40 weeks) in the delayed, and retraction between groups (H = 1.83, df = 2, P = .40). In the
29 weeks (range, 24-41 weeks) in the late group. Return to full delayed and late groups, all patients required postoperative bracing
sport was on average 9 weeks faster for early versus delayed compared with the early group, where only 41% required bracing.
repairs and was 13 weeks faster for early versus late repairs. Using
simple linear regression, we noticed that return to sport can be Twelve athletes were delayed by local sciatic nerve symptoms
predicted from time to surgery by the following formula: –104.80 (2 in the early, 5 in the delayed, and 5 in the late groups) that
1 8.89 3 17 (the intercept showed a coefficient of –104.80 [SEM, required injection therapy, and in 1 patient in the early group,
23.55]; a lower value of a reliable interval [LCL] of –160.41083; further exploration and nerve release/mobilization was performed
an upper value of a reliable interval [UCL] of –49.19171, with a t to relieve symptoms. Six athletes developed superficial wound
stat of –4.4496 [P = .00002]). Analysis of variance (ANOVA) infections, which resolved with oral antibiotic and dressings. In
suggested the effect of time to surgery on return to sport was those with delayed repairs, there were 2 partial reruptures; both
significant (F = 59.21; mean square = 6948.28; P = 6.79401E-12). ath-letes retired from competitive sport but remained recrea-
tionally active. Two others recovered well but decided not to return
to their previous level of activity. A comparison between return to
sport and complications in each group is summarized in Table 3.
The mean retraction was 3.97 6 2.02 cm (range, 1-9 cm) in the
early group, 4.4 6 2.02 cm (range, 0.5-8 cm) in the

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390 Subbu et al The American Journal of Sports Medicine

TABLE 3
Summary of Outcomes and Complications

Early Intervention Delayed Intervention Late Intervention


(\6 wk) (6 wk to 6 mo) (.6 mo) Total

Athletes, n 78 24 10 112
Elite-level athletes, n 56 7 0 63
Athletes who returned to play, n (%) 77 (98.7) 21 (87.5) 10 (100) 108
Return to activity, wk, average (range) 16 (12-32) 25 (18-40) 29 (24-41)
Rerupture, n 0 2 (partial) 0
Complications 4 superficial wound 1 superficial wound 1 superficial wound 6 superficial wound
infections; 2 local infection; 5 local infection; 5 local infections; 12 local
neural symptoms neural symptoms neural symptoms neural symptoms

DISCUSSION and multitendon tears with less than 2 cm retraction. 8 However,


when treated nonoperatively, proximal ham-string avulsions are
This series is currently the largest cohort reported in the literature, associated with continued chronic pain, weakness, poor endurance,
including elite athletes, because of the nature of the referrals reduction in function, and difficulty running. 6,29 Despite an
received. Our institute is a national referral center for these injuries increased awareness of this injury, delayed diagnosis and
and benefits from the availability of multidisciplinary services. The intervention of com-plete tendon avulsions from bone with
entire management and treatment encompasses orthopaedic
retraction continues to occur commonly. 29 Continued nonoperative
surgeons, physical therapists, and sports physicians, as well as
manage-ment of complete ruptures with or without significant
musculoskele-tal radiologists, all of whom have gained a wealth of
retraction often leads to muscle weakness, sciatic nerve
expe-rience through the volume of patients seen. The limitations of
this study are that it is an observational study over time. There are symptoms,7 and severe pain in the posterior thigh previ-ously
no randomized control trials for this interven-tion, as avulsion of a reported as the hamstring syndrome,25 leaving ath-letes with poor
major muscle complex in the elite sporting population mandates function and limited rehabilitation. Delaying the diagnosis leads to
surgical repair.10,16 more complex surgical pro-cedures due to greater retraction of the
proximal complex and the presence of fibrosis and scarring. 12
Our results illustrate that early surgical intervention is
associated with a quicker return to preinjury level of play. The Early repair within 6 weeks is associated with a superior
greater the delay to surgery, the greater the retraction of the
outcome in terms of return to high-level sports. 23 From our own
proximal hamstring complex. This increases the technical
experience, the surgical procedure is less complicated within the
complexity of the procedure, with the structures being stuck down first 6 weeks of injury in terms of identifying tis-sue planes,
and embedding the sciatic nerve, thereby increasing the chances of mobilizing tissues, avoiding nerve injury, and ease of reattachment,
a sciatic nerve injury. To prevent this safely, a larger incision for which is usually tension free, thus reducing the requirement for
sciatic nerve release is nec-essary. Patients in the delayed and late postoperative bracing. This allows for early mobilization and
groups all required postoperative bracing to protect the repair, thus rehabilitation facilitating an earlier return to preinjury-level sports.
slowing the initiation of the rehabilitation program and inevitably Delaying surgical intervention may lead to sciatic nerve symptoms,
delaying the return to sporting activity, which from the statistical including foot-drop benefiting only from surgical exploration, 25
analysis between subgroups proved to be statis-tically significant. ulti-mately leading to more complicated surgery, requiring
neurolysis, which inevitably requires a longer rehabilitation
program, delaying the return to sporting activity.
The management of complete proximal hamstring rup-tures has
been outlined in the literature. The current evi-dence has shown The majority of ‘‘weekend warriors’’ were processed through
that nonoperative treatment for complete avulsions results in primary and secondary care before eventually being referred to our
reduced functional outcomes and patient satisfaction, with
care. High-level athletes, however, have earlier access to sensitive
significantly lower rates of return to preinjury level of sport and
investigations and services. In our experience, high-level athletes
reduced hamstring muscle strength.16,17 Acute surgical repair has seek treatment early, often with imaging already performed.
significantly better patient satisfaction, subjective outcomes, pain Because of the pres-sures of high-level sport, these athletes are
relief, and strength/endurance as well as a higher rate of return to often motivated to have early intervention and early return to
preinjury level of sport,4 with reduced risk of complica-tions and preinjury levels of sport.
rerupture.16,19 Chronic surgical repair may also
It is our view that there is a population of patients with partial
improve outcomes, strength and endurance, and return to sport, but avulsions that do extremely well without surgery, but we believe,
not as well as acute repairs.8,18 and the current literature supports the view, that full avulsion
Previous studies have recommended nonoperative treatment for precludes a full functional recov-ery. Reducing the time from
single-tendon tear with or without retraction injury to surgery is associated

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Vol. 43, No. 2, 2015 Surgical Management of Complete Proximal Hamstring Avulsions 391

with reduced likelihood of sciatic nerve involvement and earlier 11. De Smet AA, Best TM. MR imaging of the distribution and location of
return to sport. Patients frequently have delayed treatment because acute hamstring injuries in athletes. AJR Am J Roentgenol.
2000;174:393-399.
of the diagnostic difficulties of differen-tiating a severe proximal
12. Folsom GJ, Larson CM. Surgical treatment of acute versus chronic
musculotendinous injury from a proximal hamstring avulsion as complete proximal hamstring ruptures: results of a new allograft
well as the tendency for athletes to consult multiple health care technique for chronic reconstructions. Am J Sports Med.
professionals before treatment. An understanding and awareness of 2008;36(1):104-109.
the severity of this injury is required to make an accurate and early 13. Garrett WE Jr. Muscle strain injury. Am J Sports Med.
diagnosis. 1996;24(6):S2-S8.
14. Garrett WE, Nikolaou PK, Ribbeck BM, Glisson PR, Seaber AV. The
effect of muscle architecture on the biomechanical failure properties
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series of 12 patients and management algorithm. Ann R Coll Surg
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Surgical intervention is a recognized treatment option for these
16. Harris JD, Griesser MJ, Best TM, Ellis TJ. Treatment of proximal
specific types of injuries, but the timing on when to operate is hamstring ruptures: a systematic review. Int J Sports Med.
crucial to avoid intraoperative challenges and postoperative 2011;32:490-495.
complications. Our study has shown that athletes of all levels can 17. Hofmann KJ, Paggi A, Connors D, Miller SL. Complete avulsion of the
return to preinjury performance levels faster after early surgical proximal hamstring insertion: functional outcomes after nonsurgical
repair of complete proxi-mal hamstring avulsions. treatment. J Bone Joint Surg Am. 2014;96(12):1022-1025.
18. Klingele KE, Sallay PI. Surgical repair of complete proximal
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19. Konan S, Haddad FS. Successful return to high level sports
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