Hospital NEO,Turku, Finland

Transcription

1 Hamstring syndrome from fibrous band to tendinosis Sakari Orava, Janne Sarimo, Lasse Lempainen, Jyrki Heinänen Hospital NEO,Turku, Finland 1

2 Hamstring muscles- ANATOMY over two big joints pelvic stabilizers hip extensors anatomical variations 2

3 Anatomy of hamstring muscle origin 3

4 Gluteal and hamstring anatomy 4

5 Radiological diagnosis of hamstring syndrome (MRI) 5

6 Hamstring syndrome Symptoms Clinical signs pain at ischial tuberosity area sitting uncomfortable and painful car driving difficult radiation to posterior thigh, seldom distally often recurrent hamstring tears in history running with long stride difficult exertion pain at ischial tuberosity and posteror thigh palpation pain over ischial tuberosity hurdler s stretch test (Puranen-Orava test) usually + side difference in forewards bending Boot removal sign + straight leg rising often+ (tightness of hamstrings) neurological status atrophy of posterior thigh in longstanding cases 6

7 Pathophysiology of hamstring syndrome = tendinosis (+ sciatic nerve irritation) Stress - microtears thickening tendinosis tendinopathy semimembranosus tendon mostly affected (=fibrous band) In runners, soccer players, other athletes, recreational athletes 7

8 Diagnosis of hamstring syndrome running,sitting and car driving difficult local pain at hamstring insertion pain during exertion MRI +, US +-, ENMG - 8

9 Conservative treatment of hamstring tendinopathia Rest from running and jumping No excessive hamstring stretching NSAID s: no help Corticosteroid injections may help Isometric hamstring exercises at different flexion angles Strength training Physiotherapy Massage 9

10 Surgical treatment of hamstring (overuse-, tendinopathy-) syndrome tenotomy of semimembr. tendon, liberation of sciatic nerve, proximal fasciotomy of thigh 10

11 Hamstring tendinosis surgery semimembr. tenotomy biceps scar, tendinosis 11

12 Surgery for hamstring syndrome HISTOLOGICAL MATERIAL : fibrosis, scarring degeneration of collagen fibres 2000: 24 biopsies in operations from proximal semimembranosus tendon (Thesis: L.Lempainen, 2009) 12

13 Biopsies and samples The biopsies were fresh frozen in isopenthane cooled with liquid nitrogen The frozen samples were stained with Herovici s method and Alcian blue for routine structural analysis CD45 immunohistochemical staining was also done to detect possible inflammatory cells 13

14 Histology of hamstring tendinopathy Rounding of tenocyte nuclei Increase in the amount of mucoid ground substance Disorganized collagen Increased vascular proliferation fibres SEEN IN ALL SYMPTOMATIC TENDONS 14

15 Histology of hamstring tendinopathy No calcification No fibrocartilaginous or bony metaplasia No signs of tendon rupture No inflammatory cells Fat cells between collagen bundles Control biopsies: no signs of tendinosis 15

16 Histology A. Normal tendon B. Disintergration of collagen fibres C. Mucin ground Substance in Alcian blue staining D. Capillary growth E. Rounding of tenocyte nuclei and increased cytoplasm 16

17 Other hamstring tendinopathies Biceps femoris sometimes tendinosis of the proximal tendon in MRI images, seen also in operations Biopsies +, but never so severe as in semimembranosus, scar, fibrosis Distal biceps tendon: tears (partial, subtotal, total) after longlasting pain 17

18 Other hamstring tendinopathies Semitendinosus: sometimes spontaneous tears of the distal tendon behind the knee and lower thigh tendinosis (?) Semimembranosus distally: very uncommon partial tears 18

19 Conclusions In tendinopathy of hamstring tendons the morphological changes are largely identical to those previously described in other more common (e.g. Achilles and patellar) tendinopathies In all analyzed samples signs of degenerative processes of various severity were detected without signs of inflammatory cells 19

20 References Puranen J, Orava S: The hamstring syndrome: a new diagnosis of gluteal sciatic pain. Am J Sports Med 1988;16: Lempainen L, Sarimo J, Mattila K, Vaittinen S, Orava S: Proximal Hamstring Tendinopahy. Results of surgical management and histopathologic findings. Am J Sports Med 2009;37: Doctoral Thesis: Lempainen L: Hamstring muscle problems: from total tear to tendinosis. University Of Turku, reports, journal articles, reviews and 50 congress abstracts 20

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