The purpose of this current concepts review is to highlight the evaluation and workup of hamstring injuries, nonoperative treatment options, and surgical decision-making based on patient presentation and injury patterns. Hamstring injuries, which are becoming increasingly recognized, affect professional and recreational athletes alike, commonly occurring after forceful eccentric contraction mechanisms. Injuries occur in the proximal tendon at the ischial tuberosity, in the muscle belly substance, or in the distal tendon insertion on the tibia or fibula. Patients may present with ecchymoses, pain, and weakness. Magnetic resonance imaging remains the gold standard for diagnosis and may help guide treatment. Treatment is dictated by the specific tendon(s) injured, tear location, severity, and chronicity. Many hamstring injuries can be successfully managed with nonoperative measures such as activity modification and physical therapy; adjuncts such as platelet-rich plasma injections are currently being investigated. Operative treatment of proximal hamstring injuries, including endoscopic or open approaches, is traditionally reserved for 2-tendon injuries with >2 cm of retraction, 3-tendon injuries, or injuries that do not improve with 6 months of nonoperative management. Acute surgical treatment of proximal hamstring injuries tends to be favorable. Distal hamstring injuries may initially be managed nonoperatively, although biceps femoris injuries are frequently managed surgically, and return to sport may be faster for semitendinosus injuries treated acutely with excision or tendon stripping in high-level athletes.

Background: Proximal hamstring ruptures meeting operative criteria may be treated through endoscopic, open, or combined techniques. Open techniques allow for facilitated tendon visualization and mobilization with ease of suture passage. Indications: Proximal hamstring repairs are indicated for complete 3 tendon avulsions; partial avulsions with 2 or more tendons involved with more than 2 cm of retraction in young, active patients; and partial avulsion injuries or chronic tears that remain refractory to conservative treatment. Technique Description: Through an incision along the gluteal crease, the tendon stump is identified and mobilized. Anchors are placed in the prepped ischium and sutures are passed through the tendon in a running fashion. The tendon is secured to its origin in a docking technique. Results: Patients undergoing hamstring repair have high satisfaction rates and patient-reported outcome scores. Competitive and elite athletes have demonstrated reliable return-to-sport rates at presurgical levels. Discussion: Open proximal hamstring repairs produce reliable results. The open technique is advantageous for its ease of tendon mobilization, direct visualization, and suture passage. Patient Consent Disclosure Statement: The author(s) attests that consent has been obtained from any patient(s) appearing in this publication. If the individual may be identifiable, the author(s) has included a statement of release or other written form of approval from the patient(s) with this submission for publication.

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The hamstring muscle complex (HMC) includes the semimembranosus, semitendinosus, and biceps femoris (BF) short and long heads, all of which act to extend the hip and flex the knee. 4,5 A primary function of the HMC is deceleration of the lower limb via eccentric contraction during running and kicking movements, placing the muscles under high strain while at high stretch. [2][3][4][5][6]8 Accordingly, most hamstring strain injuries (HSIs) are "sprint-type," occurring during high-speed running. They typically affect the proximal long head of the BF at the musculotendinous junction and/or intramuscular belly. [1][2][3][4]6,[8][9][10] "Stretch-type" HSIs may also occur with end-range hip flexion and knee extension, as might be seen in dancing and kicking, and typically involve the proximal semimembranosus tendon. 1,2,4,9,10 HSIs are commonly graded as follows: Grade I -microscopic tearing with minor swelling and discomfort and little to no loss of strength; Grade II -gross partial tear with clear weakness; Grade III -complete rupture with total loss of function. 2,[6][7][8] Grade III HSIs are often traumatic injuries, such as might occur during water-skiing when there is forceful hip flexion while the knee is in full extension. 2,5,6,9,10 Grade I and II HSIs can be treated nonoperatively with a 3-phase protocol. Phase I (~0-4 weeks) seeks to prevent scar formation while minimizing atrophy. It focuses on low-impact and isometric exercises with limits on range of motion and resistance. Phase II (~2-6 weeks) encourages gradual return to full range of motion (but not end-range lengthening) with an emphasis on submaximal eccentric strengthening, trunk stabilization, and agility. Phase III (~4-8+ weeks) incorporates sport-specific drills and further agility and trunk-stabilization exercises. Eccentric strengthening is advanced to maximal effort and range of motion, with return to sport when these can be achieved without pain. 2,10 Grade III HSIs may require open or endoscopic surgical repair, with a goal of returning to sport ~4 to 6 months postoperatively. 2,

Background: The learning curve for the surgical treatment of cam deformities in femoroacetabular impingement syndrome (FAIS) presents a challenge for young or inexperienced surgeons, with the leading cause of failed hip arthroscopy being incomplete resection. Historically, alpha angle measurements are typically used perioperatively to both diagnose cam deformity and evaluate the adequacy of cam resection. The computer-assisted Styker HipCheck system offers the surgeon real-time alpha angle measurements, assisting with the execution of cam resection. Indications: The indication for use is any hip arthroscopic procedure for femoroacetabular impingement requiring osteochondroplasty of cam deformity. Advantages of the HipCheck system include shortened operative time; reduced risk of inadequate or over-resection; accelerated learning curve; no requirement of preoperative computed tomographic imaging or pre-planning; being noninvasive, portable, and not requiring additional instruments; increased patient and surgeon satisfaction; and allowance of repeated quantitative and visual assessment, which is particularly beneficial for more difficult regions, such as posteromedial and posterolateral, to view the femoral head/neck. Technique Description: Briefly, after intra-articular procedures are complete, the peripheral compartment is accessed. We prefer a T-type capsulotomy. Next, the cam deformity is registered on Stryker HipCheck software, automatically calculating alpha angles as the hip is dynamically moved through 6 registered positions. A standard cam resection is then performed. Once complete, the hip is dynamically assessed and again registered with the HipCheck system in the same 6 positions to ensure adequate resection has been performed. Results: When comparing patients with FAIS undergoing computer-guided resection or standard resection, both surgical interventions demonstrated successful reduction in alpha angle and no difference in degree of resection. In addition, the various computer-guided views exhibited good correlations to clinical radiographs. Discussion: The HipCheck intraoperative system allows the surgeon to evaluate the adequacy of cam resection through the use of automated alpha angles. Furthermore, the system offers instantaneous feedback of cam resection at any desired position of the hip. This intraoperative technology may offer less experienced surgeons an aid when performing hip arthroscopy for cam resection in the setting of femoroacetabular impingement. Patient Consent Disclosure Statement: The author(s) attests that consent has been obtained from any patient(s) appearing in this publication. If the individual may be identifiable, the author(s) has included a statement of release or other written form of approval from the patient(s) with this submission for publication.