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Surgical and Therapeutic Management of a Complete Proximal

Avulsion after Failed Conservative Approach
Manual Therapy Fellowship
Amy Kirkland, PT, SCS, OMT*
*Fellow - Regis University Manual Physical Therapy Fellowship Program
Background Case Description Results
A complete avulsion of the proximal The patient, a 24 year old female coach sustained a Hip Adduction Hip Extension Knee Flexion
hamstring insertion is rare. complete avulsion of the proximal hamstring tendon while 5

Conservative management of playing softball. 4

hamstring tears has traditionally Surgical Intervention: Hamstring reconstruction using an
focused on end-range passive Achilles Tendon allograft

stretching, modalities, and direct 2

hamstring strengthening. New Pre-surgical Findings: * SLR ROM 145 degrees; * Knee 1

evidence suggests a program that is flexion strength 4/5; * pain 4/10

more protective of the injured tissue Post-surgical ROM: SLR 90 degrees (results maintained Figure 2: Surgical image of the 8 12 28

and includes exercises such as core upon discharge at and follow up at 1 year) ischial attachment of the Achilles. Time (weeks)

stabilization and indirect hamstring

strengthening. These principle were Protocol: [PROM – 6 weeks; Bike – 4-6 weeks (PROM weeks 4-6); Running – 3 months; FUNCTION
used in the management of this Return to Sport – 6-9 months]
Phase I: ice, submaximal isometrics of LE, soft tissue mobility, lumbopelvic 60
stabilization 50

Phase II: LE isotonic in the frontal plane, double leg and single leg balance exercises, 40

hip 30
mobilizations 10

Phase III: LE strengthening in the sagital plane, Hyroworks running, agility (slow), hip 0
0 5 10 15 20 25 30
mobilizations Time in Weeks
Phase IV: Return to sport activities (agility, speed, plyometrics)
Figures 3(top) & 4(bottom): Figure 3 represents….
Figure 1: MRI shows the proximal And figure 4 shows the LEFS
hamstring avulsion.

Conclusions and
Purpose Clinical Implications
While the preliminary outcomes for
The purpose of this case study is to the patient described in this case
describe the post-surgical physical report were successful, there is still a
therapy management of a proximal need for greater numbers of patients
hamstring reconstruction. Images from L to R: 1) combination Bledsoe/hip spica brace; 2) Inverted hamstring treated in this fashion to validate the
stretch; 3) sport cord – lateral bounding principles and techniques used.