Working Diagnosis:
Complete proximal hamstring ischial tuberosity avulsion fracture

Treatment:
Initially, the patient was treated with conservative modalities including rest, ice, analgesics (Ibuprofen) with about 30% improvement in pain. Due to MRI findings of complete avulsion of the hamstring complex connected to an osseous fragment with 4.6 cm retraction, surgical repair was recommended. He subsequently underwent uncomplicated 3 anchor fixation of the proximal hamstring origin complex. Surgery was performed within 14 days of initial accident/injury.

Outcome:
There were no complications during the surgery. Post-operative recommendations included non-weight bearing for 6 weeks followed by physical therapy and gradual increase in activity.
Two weeks post-surgery, patient was evaluated for first post-operative visit. He was recovering well and had already started physical therapy. He continued to remain partial weight bearing with the use of crutches. Sutures were removed from incisions.
Six weeks post-surgery, patient was evaluated for second post-operative visit. He was recovering well and in physical therapy. He was transitioned from crutches with partial weight bearing to weight bearing as tolerated. He was instructed to not do any upper body weight lifting for at least 12 weeks post-surgery.
Twelve weeks post-surgery, patient was evaluated for his third post-operative visit. He was doing well and was cleared to resume light upper body workouts including shooting free throws and light basketball shooting.
Sixteen weeks post-surgery, patient had regained full range of motion and strength in lower extremities. Patient was able to do deep full squats and duck walk without any difficulties. He was eligible to begin return to play protocol with recommendation of slow progression from practice to games to avoid reinjury or any new injuries.

Author's Comments:
Proximal hamstring avulsion fracture at the ischial tuberosity in adolescents is uncommon. High suspicion is warranted by clinicians. Ligaments and tendons of children and adolescents can withstand more force than bones, making the apophysis more prone to an avulsion fracture. Management of proximal hamstring avulsion fracture is dictated by the severity of the symptoms and distance of the avulsed fragment. Several studies have recommended conservative treatment with non-weight bearing, limited physical activity, and rehabilitation for injuries including two or fewer tendons or bone fragment displacement of less than 1.5 - 2cm. (2, 3) Conversely, early operative intervention is recommended for injuries involving three tendons or bone displacement of greater than 1.5 - 2cm. In a systematic review, comparing the operative and nonoperative treatment of proximal hamstring avulsion showed superior outcomes, including better hamstring strength, endurance, and a greater rate of return to pre-injury sports, with operative treatment. In addition, repair within four weeks from injury had significantly better overall outcomes with reduced risk of complications and re-rupture than repair more than four weeks out (1). In conclusion, proximal hamstring avulsion fractures can be managed conservatively with physical therapy and rehabilitation if there is clinical evidence of involvement of two or fewer tendons with a bone displacement of less than 1.5 - 2 cm. However, if there is evidence of complete three tendon avulsion or bone displacement greater than 1.5 - 2cm, operative treatment within four weeks of injury has shown to have the best subjective and objective outcome and quicker return to pre-injury status.

Editor's Comments:
Ischial tubercle avulsion fractures account for 11-29% of pelvic avulsion fractures in adolescent athletes. (2, 3) Ischial tubercle avulsion fractures, while uncommon, occur in the adolescent athlete after a dynamic and forced hip flexion with concurrent knee extension, as in sprinting, jumping, and kicking. Patients may present with a history of a pop or pulling sensation at the time of the injury, gluteal pain, difficulty sitting down, pain with extension of the knee or flexion of the hip, and potentially bruising and swelling into the gluteal fold. Conservative management, including protective weight bearing, physical therapy, and home exercises are the mainstays of treatment. Surgical management is indicated for avulsion retraction of greater than 1.5 cm - 2 cm, nerve involvement, or failure of conservative management. (2, 3) Failure of conservative management can occur in up to 20-30% of patients leading to chronic pain and decrease in hamstring strength. Return to sport often takes longer, up to 6 months, in conservative management when compared to other avulsion fractures throughout the hip. (3)

References:
1. Bodendorfer BM, et al. Outcomes After Operative and Nonoperative Treatment of Proximal Hamstring Avulsions: A Systematic Review and Meta-analysis. Am J Sports Med. 2018 Sep;46(11):2798-2808
2. Eberbach H, et al. Operative versus conservative treatment of apophyseal avulsion fractures of the pelvis in the adolescents: a systematical review with meta-analysis of clinical outcome and return to sports. BMC Musculoskelet Disord. 2017 Apr 19;18(1):162.
3. Yeager et al. Pelvic Avulsion Injuries in the Adolescent Athlete. Clin Sports Med. 2021 Apr;40(2):375-384.

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