Working Diagnosis:
The final working diagnosis was chronic right distal semitendinosus tendon avulsion.

Treatment:
The patient was referred to orthopedic surgery to discuss surgical options given the high demands of his recreational sprinting activities. Discussion took place regarding limited case series reporting good results in elite athletes with both nonoperative management and surgical resection of the retracted tendon. The semitendinosus tendon is often harvested in high-level athletes for ACL reconstruction, who go on to regain 95% to 100% of their knee flexion strength. The patient elected to proceed with conservative management. His rehabilitation program included discontinuation of sprinting activities for six weeks, as well as physical therapy for soft tissue mobilization and progressive hamstring stretching and eccentric strengthening.

Outcome:
The patient completed 3 sessions of supervised physical therapy and continued a home exercise program with gradual improvement in symptoms. He then returned to running 9 months post-injury. Given his concern for reinjury with sprinting, he transitioned to long distance running. He remained asymptomatic at 14-month follow-up.

Editor's Comments:
This is an interesting case and reinforces the idea of athletes, who are used to training with some pain, often seek care when they can no longer perform their sport at their preferred level. If the athlete had been seen earlier, a surgical treatment could have been considered. Also, finding out his pre-injury warm up plan and reinforcing an appropriate warm up strategy could aid in the prevention of future injuries.
It appears his hamstring flexibility is sub-optimal and should be improved.

References:
Adejuwon, A, et al. Distal semitendinosus tendon rupture: Is there any benefit of surgical intervention? Clin J Sport Med 2009; 502-504.

Conway, JE, Cooper, DE. Distal semitendinosus ruptures in elite-level athletes: Low success rates of nonoperative treatment. Am J Sports Med 2010; 38: 1174-1178.

Lempainen, L, et al. Distal tears of the hamstring muscles: review of the literature and our results of surgical treatment. Br J Sports Med 2007; 41: 80-83.

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