Management of PHT: Surgical vs Non-Surgical Treatment

: On today's episode, management of PHT, surgery versus non-surgical treatment. Welcome to the podcast that gives you the most up to date, evidence-based information on PHT rehab. My name is Brodie. I am an online physio, but I've also managed to overcome my own battle with PHT in the past. And now I've made it my mission to give you all the resources you need to overcome this condition yourself. So with that, let's dive into today's episode. Welcome back everyone. Thanks for joining me on another episode. We have a research paper that was just released that I thought might be very interesting for everyone. After talking to Dr. Hardy and Nicholas Lefebvre a few episodes ago, it was quite a, um, well received and I got some good feedback on that particular episode because I haven't really done many episodes on surgery before. So with the success of that episode and. the release of this paper, I thought why not just do an episode on it. It was released in June 2024. So we're talking like, you know, a month old and the title of the paper is management of proximal hamstring injuries, non-operative and operative treatment. And it's kind of like a review paper, while it is a review paper, talking about different, about the anatomy, about the biomechanics, the etiology, you know, risk factors, all those sorts of things, but then get stuck into the operative versus non-operative, what's the best approach under what circumstances and seems to have some crossover advice from the surgeons that I did have on. So, uh, that's nice, but then a fair amount of interesting stuff to go through. So, um, I thought I, I thought it might be interesting just to go through it all. Let's start with the introduction. So the introduction says that It just helps set the stage when I read the introduction. Non-operative management is successful in many cases. However, the growing literature on operative management has shown excellent results in satisfaction, functional recovery, and return to sport. The purpose of this article is to review, review current evaluation and treatment of proximal hamstring injuries. They go through the anatomy of the attachment points, which we don't necessarily need to go through. They also cover the biomechanics of the certain injury. And then they talk about the epidemiology or like how common this is, which I thought might be a bit, you might find a bit interesting. So I decided to highlight this. It says injuries to the hamstring are common in both recreational and competitive athletes. Hamstring injuries account for up to 30% of new lower extremity injuries and 10 to 29% of all injuries in athletes. Injuries of the hamstring most commonly occur at the musculotendinous junction and proximal injuries only represent 12% of all hamstring injuries. So this is looking at the hamstring in general. Hamstring injuries in general seems to be at about 30% of all injuries in the athletic population. But out of all those hamstrings, it's mainly around where the muscle becomes tendon. That's what they call the musculotendinous junction. But only 12% make up the proximal part of that hamstring. Interestingly, they say that hamstring injuries are at substantial risk of becoming chronic with re-injury rates ranging from 12 to 34%. So quite a high incidence rate or re-injury rate. In relation to the mechanism of injury, now this is where I'm going to refer back to this point several times in this paper. They're referring to proximal hamstring injuries, but that can still be, you know, an acute rupture. It could also be a chronic tendinopathy. It could be a subacute tendinopathy. So there's a lot of things that it involves and a lot of the papers that they refer to as evidence, mainly revert to hamstring. strains like the muscle belly itself, but I'll get into that in a second. Anyway, the mechanism of the injury, why do these proximal hamstrings get injured? They say the mechanism of proximal hamstring injury is usually seen with an eccentric load applied to the hip, a flexed hip and extended knee causing elevated hamstring tension. We know that the eccentric portion of the loading cycle This is why I say runners. It's usually that late swing phase when the hamstring is. Eccentrically loading up the most. That's when that load is applied. And if people do a lot of eccentric work, IE a lot of like speed work when they run, then it increases hamstring load increases the likelihood of them exceeding their capacity leading to, you know, overload, overuse injuries. They continue, the hamstring is under the greatest strain at the end of the swing phase when there is eccentric contraction of the muscle fibres at maximal elongation. Activities with rapid acceleration and deceleration, sprinting, water skiing, they mentioned here bull riding. I have never seen a bull rider in my PhD clients, but they say all of those are high risk activities. Additionally, a common mechanism of injury occurs when the legs separate into the splits position. with flexion of one hip and extension of the contralateral hip. Slipping on ice or slipping on, you know, a wet floor classic into the splits and that can cause damage or rupture or tear the proximal hamstring tendons. So we're looking at two very different things. Like I mentioned this when talking to Dr. Hardy and Lefevre on the podcast, it seems to be like two camps. We've got this acute PHT, which is brought on by the splits or a very sudden onset. Then we have this thing that's chronic in nature, a slow buildup, a slow overload type of thing, which is more common and is common with like, you know, your speed workouts and that sort of stuff. They also say in here, they try to classify a lot of these injuries or try to grade them as much as possible. So when it comes to injury classification, They say that the injury location can be insertional, meaning like the bony kind of tendinous, avulsion sort of regions, at the musculotendinous junction or a mid-substance muscle injury. They refer to a paper, Wood et al tried to classify or did classify proximal hamstring injuries into five different types. Type one is your osseous or apophysial evulsions. And they say that this is mainly seen in immature patients. So like your adolescents and younger, it's essentially like a rupture where the tendon as the tendon sort of anchors itself to the bone, when there is a rupture and an evulsion, a part of that bone actually comes off and leads to that evulsion. So that's type one. Type two would be your musculotendinous junction. So injuries and overload in and around where that muscle turns into tendon. Type 3 is your incomplete tendon evulsions from the bone. Type 4 would be a complete evulsion but have a minimal tendon retraction and type 5 is complete evulsion with a significant tendon retraction. We mentioned it in previous episodes but if there is a tear and there it's close to the anchor point of the hamstring. And a retraction would be how far how much separation is between where it's torn from and where it is positioned at the moment. But that's type five and type five sort of divvies out into type five a and type five b which type five a means that there's no sciatic nerve involvement and type b being there is a presence of sciatic nerve tethering. Okay. What are our risk factors? A variety of risk factors for hamstring injuries have been described in the literature, including previous hamstring injuries. That's a big one. They say inadequate warmup, muscle fatigue, dehydration, decreased lower extremity flexibility, poor core stability, the use of antibiotics and strength imbalances. Now they referenced six different papers when finding these risk factors, and I went through all of them, or read the titles and abstracts, and these papers are referring to hamstring injuries, hamstring muscle strains, that sort of stuff. So we're kind of, it's unfortunate that we're blanketing these as like one condition, because they say, okay, these are risk factors for hamstring injuries. And they list a whole bunch of things, inadequate warm up, previous history of injury, muscle fatigue, dehydration, all that sort of stuff. But this isn't for proximal hamstring tendinopathy, this is for hamstring muscle strains, which I think is completely different, two different injuries. So, bit disappointed why they've put that on there. I think understandably so because there's not, you wouldn't be able to find the risk factors for PhD in a lot of literature. So they've gone with the hamstring strain stuff. And I would say for things like inadequate warmups, poor flexibility, poor core stability, like all those sorts of things. I wouldn't be worrying too much about PhD and those sorts of risk factors. I'd just say it's more about like your overall load, training load, accelerations, decelerations, speed workouts, hills, all those sorts of things, running mileage, all those big ticket type of factors. You wanna make sure they're all reined in and we're all very sensible when it comes to progressing those sort of things. Off note. Previous injury is the strongest risk factor, increasing the risk of re-injury up to six times. Again, this is hamstring muscle strains. They say that it is thought to be due to decreased strength of the repair scar tissue, lowering the threshold of the injury. So if there is a muscle strain, you've had a muscle strain in the past, your likelihood is increased, purely based on this poorer strength there. poorer rehab and poorer strength based on the scar tissue that's no longer being able to contract or have the amount of strength is pre injury. All right, a clinical presentation clinical examination and differential diagnosis to have that as a subsection in here. They say an acute injury to the proximal hamstring complex typically presents with a palpable pop or pain located in the gluteal or ischial tuberosity region. I guess this is with like an acute PHT, that sort of sudden onset doing the splits type of maneuver. Injuries often occur during activities with contralateral hip flexion and hip extent and knee extension. So we're looking at sprinting type of scenario. The chronic injuries, now we're talking about PHT. I guess more commonly known PhD, the chronic injury can be more subtle and that often presents as gluteal ischial tuberosity pain that radiates down the posterior thigh. So gluteal ischial tuberosity pain would be like your sit bone area that radiates down the posterior thigh, talking about the hamstring. Common injuries, chronic injuries are commonly seen in populations with repetitive hip flexion. and knee extension such as endurance runners. In this population, now they talk about a nerve that often provide some radiating symptoms. It was the PFCN. Let me just see what that was standing for again. So your PFCN, your posterior femoral cutaneous nerve. So I can say that can sometimes get irritated and they say in this population, that particular nerve symptoms are frequently predominant presenting with burning pain while sitting and direct pressure on one or more of these nerve branches. So saying that's, they're pointing that down to why sitting pain causes that radiating burning type of sensation, if any. Typical physical examination findings include a straight leg gait to avoid hip and knee flexion, which I guess is just like walking with straight legs. Posterior thigh swelling, I don't know if I've come across that too often. A palpable mass of muscle distally to the posterior thigh. So I guess if there is a retraction, if there is a full thickness tear that is quite retracted, you might be able to feel some sort of muscle mass or something further away from the attachment point. So they say that's a presentation. And they say tenderness on palpation around the issue of tuberosity. So tender to touch the sit bone area, pain with sitting, weakness in knee flexion in comparison to the other side and apprehension to flex the hip. If there is a sciatic nerve or this cutaneous nerve tethering or involvement, patients may have peristesis. like numbness pins and needles, that sort of stuff down the posterior thigh into the lower leg or even motor weakness, meaning that the nerves have been occluded or impeded in some way and causing a lack of nerve supply and then that muscle can't contract or be as strong. So hence the presentation of weakness in a number of diagnoses. may have overlapping presentations with proximal hamstring injuries and should be considered as a differential diagnosis. They say lumbosacral radiculopathy, so a radiating nerve sensation coming from the lower back or pelvic area may present with sciatic nerve related symptoms and a positive straight leg raise or straight leg test. mainly for you health professionals that listen to this. Ischiofemoral impingement is another condition I've had, I've done episodes in the past as a potential diagnosis, essentially the sit bone and the little bony ridge by the femur sort of come closer together and impede and pinch on structures in between those. And that could sometimes be tendon, that can sometimes be sciatic nerve and... term, hence the term ischiofemoral impingement. Ischio meaning like the sit bone femoral meaning the femur so ischiofemoral coming together causing some sort of impingement. So that's a they say in fact, the ischiofemoral impingement from the lesser trichanta is, is likely a frequent causative structural factor in a large number of chronic pH T cases with or without partial thickness tears. So they're going on to say that is actually quite common for people to have this presentation and diagnosis alongside chronic PHT. They also talk about piriformis or deep gluteal syndrome as an extra pelvic compression of the sciatic nerve. Patients will present with parasythesis or pain in the buttocks with a reproduction or worsening of symptoms with simultaneous hip adduction, so towards the body and internal rotation. So that's the differential diagnosis side of things. Now they talk about surgery, whether we go non-operative, whether we go operative. So we're gonna start with a non-operative treatment and talk about that first. They talk about the indications. So when someone is indicative of seeking out non-operative treatment. Most injuries can be successfully managed non-operatively depending on the patient characteristics. the number of involved tendons, the tear thickness, the presence of and amount of retraction, so how much it's pulling, where that tear is, how much it's sort of retracted, pulling away from, and the chronicity of the injury, how long they've had it for. Commonly referenced parameters that predict success with non-operative treatment include a low grade partial tear, so if they have found a tear, make sure it is of low grade tears at the myotendinous junction. So we're looking at between the muscle and tendon. We're looking at the tears involving only one tendon. So one single tendon and the tears involving two tendons with less than two centimetres of retraction. So we're looking at like the minimal, not minimal, but less severe cases. where there may be three tendons that are all retracted, or there may be two tendons that are really quite far retracted. So they say, if it's two, if there is a tear, and if so, how many tendons there are, and if so, how much is the retraction, would say that if it's less than two centimetres and two or less tendons, then you're a good candidate for non-operative treatment to start with. They say furthermore, patients with significant medical co morbidities, or lower functional demands may be candidates for non-operative treatments, regardless of the tear characteristics. So you could have three tendons torn, or you could have two tendons with a retraction of like five centimetres. But if you fit in a camp of having a lot of co morbidities, like diabetes, obesity, heart conditions, all those sorts of things. You may not be a good candidate for surgery, I'm guessing because of the complications of that surgery. And they also mentioned of also people of low functional demands, like you might be a sedentary person who doesn't need to return to sport or isn't that interested in returning to high activity, you may opt for a non operative treatment, despite how severe the condition might be. Okay, non-operative treatment modalities. What do we do with these non-operative treatments? They say initially non-operative treatment includes activity modification. I'd say that's a fair point. So modifying your running, modifying your sitting, modifying your strength training to reduce symptoms. They also say rest, which I would say probably don't rest for too long. They say non-steroidal anti-inflammatories. I would say yes, but not for too long. I would say this is just like in the acute phase if you've had a proximal hamstring injury in the last two to three days, I would say that's probably the case. And targeted physical therapy. They talk about this hamstring strengthening protocol. It's called the, I'm gonna pronounce it as-speater, I think it is, ASP. ETA are, and it's an eccentric strengthening program. And they use this as they say this is just one example of a targeted staged physical therapy program, which progressively incorporates additional movements and activities to guide the tradition, the transition back to sport. hamstring targeted rehab has been associated with decreased injury rates compared to generalized rehab programs. The Nordic hamstring exercise, an eccentric hamstring strengthening movement is the cornerstone of most rehabilitative and preventative exercise programs. Again, they're referring to muscle hamstring strains here. Yes, the Nordic exercise is great for eccentric strength, great for reducing the risk of hamstring muscle injuries. And so that's why we'd include it, especially if you're goal is to return to sport, return to running, return to change in directions, kicking, sprinting, definitely would do a Nordic hamstring exercise in there as well. What about the role of biologics? In particular, they talk about PRP injections, which sort of fits within the realm of biologics. They say there has been increasing interest in biologic adjuncts to traditional non-operative treatments such as platelet rich plasma, Although most studies have reported no difference, they say that one early RCT on patients undergoing non-operative management of acute partial thickness, single tendon, proximal hamstring injuries suggested that intra-legional PRP injections may lead to improved recovery. I had a look at this paper. It's showing that PRP was okay. They found 10 studies and looked at it. but it said that the improvement was statistically non significant, whatever that means. So I would say that like there's enough numbers enough to suggest that what they found was statistical was like relevant, but then they found it, um, non significant. So it's, they have confidence in their, their findings. but it shows that it's not significant enough like that benefit isn't significant enough to say this is worth doing. So I'm not sure why they said that here, they found it to have lead to improved recovery. So that's when I dive a bit deeper. Still on the PRP stuff, they mentioned a few other papers with low sample sizes, 14 patients here and there. They say a more recent meta analysis included 207. proximal hamstring injuries being treated non-operatively across 10 studies failed to identify a significant difference in return to play timing or re-injury rates amongst patients who did and did not receive PRP injections as part of their rehab. I spoke to Dr. Hardy a few episodes ago about this and he was very honest about his answer. And he said, yeah, the research isn't great for PRP. But hey, it's like an option that we have. We don't really have many other options after that. Surgery, surgical, non-surgical, and PRP are kind of what they have at their disposal. So I guess this is what the research does reflect this as well. PRP doesn't show to be that beneficial, not yet shown in the research. They come up with neatly with some of the authors, the authors of this paper, their recommendations. And so one of their recommendations on the topic of non-operative treatment, they say, in the author's experience, not all full thickness tears, even with retraction, require surgery to achieve a satisfactory outcome. The authors prefer initial non-operative treatment for the majority of tears meeting the above criteria. Like I said, this was something that's involving tears of two tendons with less than two centimeters retraction, partial tears, single tendon injuries, all those sorts of things would be a candidate. And then they continue and say, "'The decision to operate should incorporate patient goals and expectations, as well as medical comorbidities and functional demands. While the timing of therapy does not seem to be critically important, I guess they're meaning like the timing of strengthening and those sorts of things does not seem to be that urgent. When you do it is when you do it seems to show some improvement. They say a hamstring targeted therapy program incorporated eccentric exercises should be involved. So we're not doing these global strengthening exercises like squats. We're doing hamstring specific stuff that also includes eccentric exercises. They say that this there is not a consistently proven role for adjunctive PRP injections currently, although PRP use is an area of ongoing research. Okay, time to talk about operative treatment and the indications for operative treatment. They say the decision to perform surgery is guided by injury severity, acuity, patient factors, and surgeon experience. They say that the most important considerations for surgical treatment were the number of tendons involved, the tendon retraction and the patient activity level. Like it kind of coincides with what we said before. Common indications for operative treatment are three tendon complete proximal evulsions or two tendon evulsions with greater than a two centimeter retraction. and other partial tendon injuries that have failed non-operative management for minimum three months. When talking about, well, they then go on to a few things that I think was above the scope of today's episode. They talk about the endoscopic repair versus open repair. So the two different types of surgery, what's involved, how to prep for it. It's kind of like a lot of this stuff was designed for, I guess, guiding. surgeons or guiding the medical side of things. They're talking about like, where the open wound incision is, like what's, you know, I guess how the operation is conducted. So you can check out the paper if you want to know more about that. There's essentially the open repair, which is a little bit more invasive, a little bit more like, you know, in terms of the incision side, they open things up and they do a lot more work there. Whereas the endoscopic repair, is minimally invasive, it's just like, you know, using less instruments, less of a scar, less of an opening, that sort of stuff. Most people will be familiar with like an endoscopic, they might do a arthroscope or something in your knee where they have like different portals, different incisions to then do some clean up of a meniscus or something like that, but it's less invasive. Okay, let me scroll down because they talk about the outcomes and complications. They say there have been many studies in recent years evaluating the outcomes of proximal hamstring injury treatments. However, the majority are small and retrospective with conflicting findings. Over the past two decades, more systematic reviews have been published that provide valuable insight into the treatment of proximal hamstring injuries. A systematic review by Hylia Smith analysed 35 studies for a total of 1530 proximal hamstring repairs. They reported that surgical treatment of proximal hamstring injury, regardless of technique, has a high satisfaction rate, improved strength, and enhanced functional clinical outcomes and return to sports compared to non-operative treatment. They also reported that surgical treatment of acute compared to chronic injury had significantly faster return to sport times, lower re rupture rates and decreased rates of sciatic nerve dysfunction. So if it is one of those acute sudden onset PHTs, it seems like the outcome is more favorable for surgery compared to those with a chronic PHT. In a recent systematic review evaluating complication rates after surgical treatment of proximal hamstring injuries by Lawson et al, the authors evaluated 43 studies and included 2,833 proximal hamstring repairs. They found an overall complication rate of 15%, which is substantially lower than previous reported rates of 23%. They don't mention exactly what the complications are, say that it's at 15%. However, these authors acknowledged that they were unable to further compare complication rates between open and endoscopic repair, partial or and complete injury and acute versus chronic injury. Talking about the predictive factors of return to sport. Several studies have sought to identify predictors of return to sport after operative professional athletes undergone surgical treatment of proximal hamstring injuries, found that patients who were male sex had isolated semi-membranosus injuries, which is one of the muscles of the hamstring, and had proximal hamstring-free tendon ruptures were more likely to have earlier return to sports. In a systematic review from 2009 of 16 studies, there was a trend towards quicker return to sport with earlier surgical intervention, which is similar to the finding on the Hillier Smith paper suggesting that acute injuries had faster return to sport times. I think this is similar to what the surgeons were saying in the podcast, talking about the window to surgery and better outcomes for those with complete hamstring ruptures. the quicker return to sport with the operative versus non-operative. Okay. Author recommendations based on the current literature and our experience for acute, partial, and complete tears with minimal retraction. The authors prefer endoscopic techniques for proximal hamstring repair for retracted and more chronic tears. We prefer the open approach for proximal hamstring tears. So that's kind of, while also considering the indications for operative versus non-operative that I discussed earlier. Okay, post-operative rehab. So if you have or decide to eventually do surgery, what does the treatment look like after surgery? They say post-operative rehab protocols after proximal hamstring repair have been shown to be highly variable in the timing of strengthening, in terms of stretching, in terms of completion of standardized return to sport criteria before resuming training. While this is in an area of future research and an opportunity to improve patient care, the author's recommendation for post-operative proximal hamstring repair is outlined below. So they talk to this in about of like four phases included within certain week parameters. So they say phase one is between week zero and week six. So we're looking at the first month and a half. They say that the goal of this phase is wound healing and pain control. Patients typically do not start formal physical therapy until weeks four to six post-op. Patients are permitted to be touched down weight bearing. So maybe with crutches, only just slightly touching the floor. The affected side only just slightly touching the floor. A hinge knee brace is worn locked at 45 to 50 degrees until week four to six. So you're pretty much in a brace for the first four to six weeks. Patients are instructed to avoid hip flexion with knee extension. So that's like bending over, trying to pick something up off the floor with straight legs. Of note, allowance of knee extension while upright and passive flexion to 90 degrees while seated has demonstrated good outcomes after proximal hamstring repair. So we wanna avoid hip flexion, bending at the hip while the knee is straight. However, bending at the hip when the knee is bent is okay. So that's the first six weeks. Now we're talking six to 12 weeks, we're moving into phase two. They say from weeks four to eight, the patient begins gradually progressing active knee flexion in the brace. Weight bearing is progressed as tolerated as the patient is weaned from crutches. The goal of this phase is to normalise gait, get to normal walking, with full range of motion and initiate basic functional movements such as partial squats without exceeding 60 degrees of knee flexion, so small squats. So that's the first one to three months. So they say weeks six to 12. Now we're looking at phase three, which is weeks 12 to 16. The goal of this phase is to continue progressing, is to continue progression of hamstring strengthening, including beginning of strengthening of the hamstrings in a lengthened position. Jogging slash light running may be initiated in this phase. Very vague, isn't it? It's like, okay, we're three months into it, three months in, we haven't really started any strengthening exercises yet. Only just, you know, return to normal. movements and normal function. Now it's time for dedicated strengthening. They don't really give us many strengthening exercises, they just say, okay, start strengthening. And by the way, you can also do some jogging slash light running, I would say, there's a lot to unpack there, I'd say definitely want to be doing a lot of strengthening and eccentric stuff before considering jogging or light running. But that's what it says. Phase four is 16 plus months. So we're 4, 8, 12, 16. So we're four plus months into post-op. And they say that now sports specific movements and impact are initiated. Return to sport criteria includes less than 10% deficit of functional tests, and side to side testing compared to the contralateral side. So they say, okay, it's time to start talking about a return to sport. Let's look at your strength deficits and your functional deficits. if there is more of a deficit beyond more than 10% deficit, then we're not ready, we need to keep with three-hat before then talking about return to sport. So again, very vague with those sorts of things. What else did I pick up? So there was an additional author recommendations, which I only highlighted a few of them that I thought might be interesting. One of them was that full thickness retraction tears can be endoscopically repaired if the tendon is reasonably mobile for anatomic repair, which is usually within the month of the injury. However, endoscopic repair is still possible in chronic cases with large retractions and may provide a safer technique approach for nerve protection. Endoscopic repair in this setting is technically challenging and may have reduced fixation strength compared to an open repair. They also said, that diabetes is a risk factor for failed or repair failure. So just bear that in mind as well. Okay, in conclusion, proximal hamstring injuries are common and important to accurately diagnose at presentation. Most hamstring injuries can successfully be managed with non-operative treatment. However, in the cases of complete rupture, two tendon tears with retraction and injuries refractory to non-operative. operative treatments, surgical repair is warranted. Open repair techniques have traditionally been employed. However, the literature for endoscopic repair is increased in the recent years and is shown to have excellent outcomes. Careful post-operative management and mindful rehabilitation are crucial to limit complications and to improve success after surgical repair. Okay, so. Like I say, the title of this paper is the management of proximal hamstring injuries, non-operative and operative treatment. The lead author is Thomas R. Yetter, Y-E-T-T-E-R, if you are interested in looking that up. Hopefully that's provided some insights and a nice like follow one from the conversation I had with the two surgeons earlier. And hopefully this is... received and has the same feedback as that last episode. So hope you enjoyed this session. Hope you enjoyed this episode. Good luck with your rehab this week and we'll catch you in the next episode. If you are looking for more pht resources then check out my website link in the show notes. There you will find my free pht five-day course, other online content and ways you can personally connect with me including a free 20-minute injury chat to discuss your current rehab and any tweaks you might need to make. Well done for taking an active role in your rehab by listening to content like this, and together we can start ticking off all of your rehab goals and finally overcome your PHT.