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Case of the Month - February 2020

Patient Testimonial: Extremely happy with the procedure Dr. Ziegler performed. I had a rare case of snapping hamstring tendons that most doctors hadn't dealt with before, but Dr. Ziegler was confident in his abilities to fix this problem and I couldn't be happier. THANKS!!

Snapping Medial Hamstring

Snapping medial hamstrings in a rarely reported diagnosis that usually occurs because one of the pes anserine tendons, either the gracilis or semitendinosus, will get caught in scar tissue. During flexion and extension of the knee, and the tendons will slip over each other and often have an audible snap back into place. This can be associated with pain and very annoying to patients. Snapping medial hamstrings can occur after meniscus repairs, after ACL surgeries, after trauma, and sometimes occur spontaneously with no known trauma. The sounds that snapping hamstrings make can be quite audible and dramatic (see video below)!

Pre-operative video of symptomatic snapping medial hamstring. Listen closely to hear pop!

Treatment for Symptomatic Snapping Medial Hamstring

The treatment of medial snapping hamstrings involves eliminating the cause of the snapping. Unfortunately, this is such a rare condition that a definitive treatment course has not been determined. In some patients, it has been found that simply releasing the gracilis and semitendinosus tendons at their attachment along the pes anserine bursa, followed by scar tissue release of the tendons proximally, is successful at relieving the snapping symptoms. Excision of the snapping hamstring tendon(s) with an open hamstring harvester can also be performed. However, even in the best of circumstances, recurrent snapping can occasionally occur because the hamstring tendons can regenerate, with studies demonstrating regeneration on ultrasound as soon as 6 weeks to 3 months after their excision (these studies were performed for ACL reconstruction hamstring harvest evaluation).

Case: 27 year old otherwise healthy and active male who sustained a left knee hyperextension injury at work. He developed soreness, mild swelling and started noticing a snapping sensation along the back and inside (posteromedial) portion of his knee. He was seen by a few different providers before coming to us. He clearly demonstrated snapping medial hamstring tendons, particularly the semitendinosus. A dynamic ultrasound was also performed confirming his diagnosis. He failed conservative treatment including activity modification, injection and NSAIDs. He underwent knee arthroscopy with open harvest of his semitendinosus tendon and release of adhesions and tissue bands of his gracilis tendon. He started physical therapy within 2 days of surgery and was allowed to be weight bearing as tolerated immediately with crutches until walking without a limp. At 2 months post-op, he had no pain or snapping, was back to most activities and was very happy with his outcome!

Left knee MRI showing the semitendinosus hamstring tendon crossing over the semimembranosus tendon with some mild edema (inflammation) between the two. Sagittal view on left and axial view on right.

Post-operative video 2 months after surgery. No more pain or snapping!

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