A review of 179 cases of injury to the hamstring muscle complex (HMC) using ultrasound (102 cases) and MR (97 cases) showed there were 21 injuries involving the proximal insertion on the ischial tuberosity with 16 tendon avulsions; 154 injuries of the muscle belly, and only 4 injuries of the distal tendon or bone insertion site . Approximately 80% (124 cases) of injuries involved the biceps femoris (54 proximal, 48 mid, and 22 distal); 61% involved the myotendinous junction and 35% were considered epimyseal or involving the periphery of the muscle. Multiple muscle involvement was only seen in 5% cases for these authors, others have shown using MR primarily that multiple muscle injury occurs nearly 30% to 40% of the time [13,14,21].
MR correctly identified all of the proximal hamstring avulsion injuries (16/ 16), whereas those patients who also underwent ultrasound evaluation had the avulsion injury detected in slightly more than half of the patients (7/12) (Fig. 7). The authors did find ultrasound useful for detecting distal superficial injuries (fairly uncommon) involving the distal semitendinosus and semimem-branosus tendons. Operator dependence and skill were noted to be a factor for successful interpretation of muscle injury using ultrasound.
A more recent longitudinal study of hamstring muscle injures compares so-nography with MR in 60 professional Australian Rules football players . All players were imaged within 3 days, at 2 weeks, and 6 weeks with both modalities. Sonography detected 45, 25, and 10 cases of injuries over the three time frames and MR detected 42, 29, and 15 injuries respectively. All injuries appeared larger (length and cross-section) on MRI at all time points. The length of the tear measured on coronal images and the cross-sectional area on MRI
was the best predictor for time to return to competition. Tears showed decreased cross-sectional involvement over time with both modalities. Ultrasonography was found to be more useful for evaluating epimyseal injuries and MR better for intramuscular tendon abnormalities. Distribution of injuries confirmed biceps femoris as being most commonly injured typically along the intramuscular tendon. There was no significant difference in return to play for epimyseal injury versus myotendinous junction injuries. This study also showed a relative infrequent association with multiple muscle injuries (about 5%). While ultrasound was good, bulky musculature in athletes limited its use and overall, the authors felt MR was the preferred modality for the elite athlete when there is concern for optimizing rehabilitation and a need for follow-up imaging.
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