SPORTS MEDICINE Total proximal hamstring ruptures: clinical and MRI aspects including guidelines for postoperative rehabilitation Carl M. Askling • George Koulouris • To¨nu Saartok • Suzanne Werner • Thomas M. Best Received: 3 July 2012 / Accepted: 19 November 2012 / Published online: 11 December 2012 Ó Springer-Verlag Berlin Heidelberg 2012 Abstract The aim of this article is to provide a state-of-the- art review for treatment of acute, total proximal hamstring tendon ruptures. For total proximal hamstring tendon rup- tures, early (\2–3 w) surgical refixation minimizes muscle atrophy and facilitates a somewhat predictable time course for healing and rehabilitation. A postoperative rehabilitation program is detailed that has been used by one physical ther- apist for the past 7 years on over 200 patients with surgical repair for total proximal hamstring tendon rupture. One re- rupture has occurred, 7 months after surgery, following the rehabilitation program described herein. The rehabilitation program, including avoidance of postoperative bracing, appears effective for total proximal hamstring ruptures. Early surgery together with a specific rehabilitation program appears to be the treatment of choice for timely and safe return to sport and an active lifestyle. Level of evidence V. Keywords Physical therapy Á Surgical treatment Á Tendon injuries Á Thigh muscle injuries Introduction Acute injury to the hamstring muscle group represents the most common muscle injury in sports. More importantly, despite the prevalence of these injuries and basic and clinical research in this area, recent studies have suggested a lack of progress in both primary and secondary prevention of hamstring injuries [15]. Injury to the hamstring muscle group can occur at a variety of locations including proximal or distal musculoten- dinous junction, muscle belly, and proximal as well as distal tendon avulsion. In this paper, we will focus attention on the total proximal hamstring rupture, a topic of increasing interest given the problems associated with long-term morbidity and the absence of definitive studies regarding indications for surgical treatment as well as evidence-based rehabilitation programs. Our intent is to motivate future research to more completely address this clinical problem that fortunately is not as frequent as the so-called hamstring strain, yet its manage- ment even in the best of hands can result in inability to return to sport at the previous level of activity as well as chronic com- plications including pain and loss of function. C. M. Askling (&) The Swedish School of Sport and Health Sciences, Stockholm, Sweden e-mail: carl.askling@ihs.se C. M. Askling Section of Orthopaedics and Sports Medicine, Department of Molecular Medicine and Surgery, KarolinskaInstitutet, Stockholm, Sweden G. Koulouris Melbourne Radiology Clinic, East Melbourne, Australia G. Koulouris Centre for Orthopaedic Research, School of Surgery, University of Western Australia, Nedlands, Australia T. Saartok Á S. Werner Sports Trauma Research Center, Karolinska Institutet, Stockholm, Sweden T. Saartok Department of Orthopaedics, Visby Hospital, Visby, Sweden S. Werner Department of Molecular Medicine and Surgery, Stockholm, Sweden T. M. Best Department of Family Medicine, Sports Health and Performance Institute, The Ohio State University, Columbus, OH, USA 123 Knee Surg Sports Traumatol Arthrosc (2013) 21:515–533 DOI 10.1007/s00167-012-2311-0