Ask a Sports Medicine Doc column: Water skiing injury likely a hamstring injury
Question: I was recently water skiing in Lake Powell when I took a bad fall and felt a tear in my buttock. I had immediate pain and then difficulty walking. What do you think I did?
Dr. Rick Cunningham: It sounds like you might have torn one or more of your hamstring tendons from their origin off your pelvic bone. This is not an uncommon injury in water skiing. I have actually had to surgically repair a number of these in water skiers during the years. In this injury, patients often describe the sensation of being shot in the back of their thigh and buttock. They feel a pop and have immediate pain, swelling, bruising and can only walk stiff-legged. Patients also have a lot of pain with sitting.
After examining a patient in the office with a probable hamstring tear, I obtain an MRI scan. This shows whether the patient has sustained a partial tear or a complete tear of their hamstring tendons off of the pelvic bone where they attach, which is your sit bone or ischial tuberosity. Moreover, the MRI shows whether someone tore all three of the hamstring tendons or just one of them. The three hamstring tendons that originate off of the ischial tuberosity are called the semitendinosus, semimembranosus and the long head of biceps femoris.
If someone partially tears their three tendons, or if they completely tear just one of their hamstring tendons off the ischial tuberosity, then surgery is not required. Treatment consists of rest, ice, physical therapy, ultrasound, anti-inflammatory medications, gentle stretching and gradual return to athletic activity over approximately four to six weeks.
However, if someone tears all three tendons and they are pulled away more than an inch or so, then surgery is recommended. Without surgery, patients usually experience chronic pain and weakness in hip extension and knee flexion. Moreover, they can develop nerve pain in their leg if the torn hamstring tendons then scar down to the nearby sciatic nerve and pull on it. Simple things such as sitting can continue to be painful if the tendons are not properly repaired. Thus, it is best to diagnose and then fix these tears early while the tendons are easily mobilized and not scarred onto the sciatic nerve and surrounding tissues.
Surgery consists of making a transverse incision in the crease just below our buttock (which makes for a scar that is hardly noticeable), isolating the torn tendons and suturing them back to the ischial tuberosity using suture anchors. Patients are on crutches with limited weightbearing initially, and they are also placed in a brace after surgery. Hip flexion is avoided to protect the tendon repair. Unfortunately, it can take nine months or so to return to all sports.
Fortunately, it is much more common for athletes to strain their hamstrings rather than tear them. This usually results from an eccentric contraction. In other words, the muscle is contracting while the muscle fibers are being elongated. Think of catching a heavy object with your hand as it falls off a shelf. Your biceps muscle is suddenly contracting, but your elbow is straightening in an effort to reach out and catch the object, thus elongating the biceps’ muscle fibers. Eccentric contractions place enormous stress on a muscle tendon unit and can tear it. Hamstring strains typically occur at the muscletendinous junction, or where the muscle fibers start to become tendon fibers. This is the weak link in any muscle tendon unit, whether it be your hamstrings or your biceps. Fortunately, these strains tend to heal uneventfully as they have good blood supply from the surrounding muscle tissue.
Dr. Rick Cunningham is a knee and shoulder sports medicine specialist with Vail-Summit Orthopaedics. He is a physician for the U.S. Ski Team and chief of surgery at Vail Valley Medical Center. Do you have a sports medicine question you’d like him to answer in this column? Visit his website at http://www.vailknee.com to submit your topic idea. For more information about Vail-Summit Orthopaedics, visit http://www.vsortho.com.