Treatment of Partial Thickness Rectus Femoris and Proximal Hamstring Tears
Initial Conservative Management (First 6-12 Weeks)
For this patient with partial thickness tears of both the rectus femoris tendon and proximal hamstring with hematoma, initial treatment should be conservative with relative rest, NSAIDs for pain control, cryotherapy, and a structured eccentric strengthening program, reserving surgery only if symptoms persist beyond 3-6 months of comprehensive rehabilitation. 1, 2
Immediate Management (First 2-4 Weeks)
Relative rest is essential—the patient should avoid running and activities that reproduce the pain (sprinting, rapid acceleration), while maintaining activities that don't aggravate symptoms to prevent muscular atrophy and deconditioning 1
NSAIDs (such as ibuprofen) provide effective short-term pain relief, though they do not alter long-term outcomes; topical formulations eliminate gastrointestinal hemorrhage risk while providing equivalent analgesia 3, 4
Cryotherapy through a wet towel for 10-minute periods should be applied multiple times daily for acute pain relief 1, 3
Complete immobilization must be avoided as it causes muscular atrophy and deconditioning, which will prolong recovery 1, 3
Progressive Rehabilitation (Weeks 2-12)
Eccentric strengthening exercises are the cornerstone of rehabilitation for both rectus femoris and hamstring tendinopathies, with proven efficacy in multiple tendinopathies 1, 3
For proximal hamstring tendinopathy specifically, eccentric hip extension exercises using a treadmill have demonstrated excellent results, with patients noting decreased pain within 2 weeks and return to running within 4 weeks 5
Lumbopelvic musculature strengthening should be incorporated as an adjunct to hamstring-specific exercises 5
Physical therapy should focus on restoring full strength, endurance, flexibility, coordination, and agility before return to running, as inadequate rehabilitation is the primary cause of recurrent hamstring injuries 6
Important Caveats About Corticosteroid Injections
Corticosteroid injections should be used with extreme caution, if at all—while they provide short-term pain relief, they do not improve long-term outcomes and may have deleterious effects on tendon healing 1, 3, 4
Never inject directly into the tendon substance, as this inhibits healing and may predispose to rupture; peritendinous injections are preferred if injection is deemed necessary 3, 7
Surgical Indications
Surgery should only be considered after 3-6 months of comprehensive conservative treatment failure, as most patients (approximately 80%) fully recover with conservative management 1, 3
Specific Surgical Criteria for Hamstring Injuries
Operative treatment is traditionally reserved for: 2-tendon injuries with >2 cm of retraction, 3-tendon complete ruptures, or injuries that do not improve with 6 months of nonoperative management 2
This patient's injury does not meet surgical criteria based on imaging—the hamstring shows tendinopathy with probable partial thickness tear and hematoma (4.3 x 2.8 x 2.2 cm), but this represents a contained hematoma within the tendon rather than a complete rupture with retraction 2
The rectus femoris partial thickness tear (9 x 6 x 2 mm defect) is small and does not warrant surgical intervention at this stage 1
Surgical Techniques (If Eventually Required)
Surgical options include excision of abnormal tendon tissue and longitudinal tenotomies to release scarring, with both endoscopic and open approaches available for proximal hamstring repairs 3, 2
Acute surgical treatment of proximal hamstring injuries tends to be favorable when indicated, with complete functional and radiological resolution possible following surgical repair of significant tears 2, 8
Return to Activity Criteria
Permission to return to running should be withheld until: complete return of muscle strength, endurance, and flexibility, plus restoration of coordination and athletic agility 6
Failure to achieve full rehabilitation predisposes to recurrent injury, which is common with hamstring injuries due to inadequate initial rehabilitation 6, 9
The patient should expect gradual return to running after 4 weeks if responding well to eccentric exercises, with speed training after 12 weeks and competition shortly thereafter 5
Critical Pitfalls to Avoid
Do not allow premature return to running—the "pop" felt 2 weeks ago indicates significant injury, and rushing back will lead to recurrence 6
Avoid multiple corticosteroid injections despite their appeal for short-term relief, as they may weaken tendon structure 3, 4
Do not proceed to surgery without adequate conservative trial of at least 3-6 months, as even large tears can achieve full functional recovery with conservative management 1, 9
If multiple tendons remain symptomatic despite treatment, evaluate for underlying rheumatic disease 1, 4