The clinical case of the neglected damage of the semitendinous, the semimembranous and the biceps femoris muscles in an adolescent judo athlete

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RELEVANCE

The semimembranosus, the semitendinosus and the biceps femoris muscles (the hamstring muscles) are the biarticular synergists (with the exception of the short head of the biceps muscle), the function of which is to flexion and to rotate the shin, as well as to extend the thigh [1, 2]. The injuries in the said muscles are more characteristic for professional athletes; the incidence rate varies from 12% to 26% of all the injuries inflicted during the sports activities [3–6].

The higher risk of injury is observed in such types of sports where the prevailing activities include running, jumping, kicking (obstacle race, soccer, football, rugby, taekwondo) [7–9]. Sudden movements with combining the hip flexing and the extension of the shin, cause the acute muscle damage in their biomechanically weak zones — the areas of their attachment and the transitions of the tendon part into the muscle [10–12]. For the athletes choosing such a type of competitive sports as judo, the injuries of such type are not characteristic, which is demonstrated by the results from the systematic review devoted to the injuries inflicted during the judo tournaments [13]. The most common injuries among judokas are ligament injuries (42–66%), joint dislocations (12–57%), and fractures (15–24%). Head, neck, and upper extremity injuries predominate, accounting for up to 55% of all injuries [14–16]. The rupture of the flexor muscles in the shin among the judokas are infrequent, while the neglected cases of such injury were not described at all [17, 18].

Here we provide a description of our own observation of the professional adolescent judo athlete with a neglected injury of the semitendinous, of the semimembranous and of the long head of the biceps femoris muscle (m. semitendinosus, ST; m. semimembranosus, SM; m. biceps femoris, Biceps^LH).

CLINICAL CASE DESCRIPTION

Patient info

The adolescent aged 17 years was admitted to the National Medical Research Center for Pediatric Traumatology and Orthopedics named after G.I. Turner for our follow-up with the complaints of increased fatigability in the flexor muscles of his right shin and pain in the back of the right thigh (according to the patient, “the back muscles of the right thigh are cramping”).

Case history. Three years before the admission, the patient had an injury of his right thigh as a result of incorrect falling during the competition at the judo tournament (Fig. 1), after which he had presented to the Trauma Unit of the Regional Clinical Hospital at place of residence. Based on the results of ultrasound examination, a post-traumatic swelling of the soft tissues was diagnosed. Later on, the patient had a long history of pain syndrome, limiting the ability of long-term walking. In one and a half year after injury, the patient has once again visited the physician at place of residence with undergoing the magnetic resonance imaging (MRI) of his thigh: according to the conclusion, “no data were obtained for confirming the presence of nodular lesions within the soft tissues of the middle third of the thigh; the findings include the local swelling in the fibers of the gracilis muscle and the deformations in the adjacent fatty tissue of post-traumatic nature”. From the moment of injury, for relieving the pain syndrome, the patient was taking non-steroid anti-inflammatory drugs. No immobilization was done, no conservative or surgical treatment methods were applied. As for the dynamic changes — the patient started noticing weakness when flexing the right shin, weakness in the right lower extremity when walking.

 

Fig. 1. Clinical-anamnestic data: а — moment of injury (video-recorded) during the tournament (the injured athlete is marked with the arrow); b — ecchymosis along the posterior-internal surface of the right thigh after injury.

 

The patient was examined 3 years after the injury: hospitalization was recommended for examination and determination of treatment tactics.

Clinical examination, Laboratory and Instrumental Diagnosis

The patient ambulated independently, without additional support, with a slight right-sided. Upon the visual examination, the axes of the lower extremities are normal, without deviations. The thigh circumference at the level of the upper, the middle and the lower third is symmetrical. Upon palpation with the shin flexed, over posterior-internal surface of the right thigh, the findings included the defect (interruption) of the muscle belly, which was not found on the contralateral side. The motion amplitude (by the zero point method) in the right coxofemoral joint was the following: flexion/extension 100/0/5 (where 100 — is the flexion; 0 — is the neutral position; 5 — is the extension), abduction/adduction 55/0/15, internal/external rotation 35/0/30; in the right knee joint — 120/0/0; in the ankle joint 45/0/5. The muscle strength of the flexor muscles in the shin on the left side was 3 points, on the right side — 5 points.

In the prone position, muscle endurance was assessed by holding the limb, fully extended at the joints, above a contact surface: on the left side — 2 minutes, on the right side — 18 seconds. When evaluating the functions of the injured limb using the Lower Extremity Functional Scale (LEFS), a total of 49 points were reported, which indicates the presence of significant limitations.

The patient was examined by the Neurology Physician: when conducting the Puranen–Orava test, the patient develops the uncontrolled muscle spasm and pain in the back of the thigh. Other findings were the insignificant decrease of the Achilles tendon reflex (hyporeflexia) at the affected side; the patellar reflex is active and symmetrical.

On admission to the center, the patient underwent the x-ray examination of the lower extremities, in particular, the panoramic radiography and the computed tomography (CT) of the lower extremities; the comparative MRI of the soft tissues in the right and the left thigh (Fig. 2). X-ray and CT scans revealed no osteoarticular pathology. MRI revealed injuries of varying severity to all three muscles: SM, ST, and Biceps^LH (arranged in descending order; see Fig. 2, а). The long head of the biceps femoris and the semitendinosus muscle were, probably, torn off at the places of their attachment and did not undergo significant retraction; the origin of belly of the semimembranosus muscle was visualized at the border between the upper and middle third of the thigh (9 cm of retraction).

 

Fig. 2. Comparative magnetic resonance imaging of soft tissues of the right and of the left thigh (axial and frontal slices): а — changes in the normal architectonics of the semitendinous, the semimembranous and the long head of biceps femoris muscle at the level of the upper third of the right thigh; b — at this level, there is no trackable muscle belly of the semimembranous muscle; c — at the border between the upper and the middle third, the semimembranous muscle belly is trackable as adhered to the adductor magnus; difference was determined in the shape and the diameter of the semitendinous muscle cross-section; d — at the level of the middle third, there is a clearly trackable muscle belly of the semitendinous muscle, the non-conformity of the transverse diameter of the semimembranous and the semitendinous muscles comparing to the contralateral side, the hypertrophy of the short and long head of the biceps femoris; e — similar picture is at the border of the lower and middle third. ST (m. semitendinosus) — semitendinosus muscle; SM (m. semimembranosus) — semimembranosus muscle; Biceps^LH (m. biceps femoris) — the long head of the biceps femoris muscle.

 

The data from the electroneuromyography were showing a decreased pulse conduction at the level of the middle third of the thigh, as well as the conduction block and signs of denervation in the damaged muscles.

Diagnosis

As a result of the clinical-instrumental examination, the patient was diagnosed with the neglected injury of the semitendinous and the biceps femoris muscles with insignificant retraction, the injury of the semimembranous muscle with significant retraction and the neuropathy in the right sciatic nerve.

Taking into consideration the data from the conducted examination, the injury type 6 was determined in a patient acc. to the Wood classification (table 1) [19], requiring the surgical treatment with the neurolysis of the sciatic nerve. The planned extent of surgical intervention was taking into account the significant retraction of the semimembranous muscle with the satisfactory preservation of the semitendinous and the biceps femoris muscles, as well as the patient’s absence of the will to return to professional sports, due to which, a decision was drawn on performing the myolysis, the tenolysis, the neurolysis and the myotenodesis of the semimembranous muscle to the semitendinous one.

 

Table 1 Wood Classification for the avulsions of the proximal end of tendon

Type	Type of lesion	Recommendations
1	Avulsion fracture	Surgical excision of a bone fragment with restoring the fixation of the tendon, if the displacement is >1–2 cm
2	Musculotendinous junction	Most cases can be treated conservatively. The professional athletes with ruptures, probably, require surgical treatment
3	Incomplete/partial avulsions	Initially treated conservatively, however, in part of the patients, conservative therapy can be ineffective, which requires surgical intervention. The initial restoration should be suggested for professional athletes with partial avulsion with high degree of severity
4	Complete avulsion with no/insignificant tendon retraction	Restoration is recommended for athletes for returning to the functional status before injury. Non-surgical treatment can be attempted in patients with low functional requirements
5	Complete avulsion with tendon retraction	Repair recommended
6	Complete avulsion with tendon retraction and sciatic nerve compression	Repair with neurolysis of the sciatic nerve recommended

 

Treatments

With the patient in a prone position, with a cushion under the right shin to flex the knee joint by 30 degrees, access to the injured muscles was achieved through a 20 cm linear incision. Upon the revision, high number of adhesions was found along the muscles, in the proximal part the ST and the Biceps^LH muscles were adhered to each other: the myolysis was performed (freeing the muscle tissue from scars and adhesions). At the level of the middle third of the thigh, the torn off SM muscle belly was visualized and mobilized, the proximal edge of which had no connection to its own tendon (Fig. 3, а). Under the SM belly, within the scar tissue, the SM tendon was visualized: the tenolysis was performed (freeing of the tendon tissue from scars and adhesions), the tendon was mobilized to the level of the upper third (Fig. 3, б). The findings included the presence of scar adhesions along the sciatic and the motor branches of the nerves heading to the SM and ST muscles: the neurolysis was performed (decompression) of the sciatic nerve and its branches. During test flexion, corrugation of the mobilized SM tendon is observed (see Fig. 3, в): plication was performed (decreasing the dimensions by creating the fold) along with the suturing of the tendon with shortening it by 3 cm. At the position of the knee joint bent by 50 degrees (see Fig. 3, г) the proximal part of the SM muscle belly was sutured to own tendon, with the tendon and the muscle belly being sutured to the semitendinous muscle, the myotenodesis was performed (creating the artificial connection between the muscles and the tendon; see Fig. 3, д). During the course of surgery, a careful hemostasis was followed; the wound was sutured without drainage. The limb was immobilized with posterior plaster cast from the upper third of the right hip to the lower third of the right shin at the flexed position of the knee joint — by 30 degrees.

 

Fig. 3. Steps of surgical intervention: а — myolysis of the torn belly of SM; b — tenolysis of the SM tendon; c — corrugated tendon of SM upon the knee bending test; d — temporary fixation of the shin at the 50° flexed position for suturing; e — visual picture after plication and the myotenodesis. ST (m. semitendinosus) — semitendinosus muscle; SM (m. semimembranosus) — semimembranosus muscle; Biceps^LH (m. biceps femoris) — the long head of the biceps femoris muscle.

 

Thus, the patient has received surgical treatment that included the myolysis, the tenolysis of the flexor muscles of the shin, the neurolysis of the sciatic nerve branches, the plication of the semimembranous muscle tendon and the myotenodesis of the semitendinous muscle.

Follow-up and outcomes

On Day 5 after surgery, the patient was discharged for further out-patient treatment; immobilization was recommended for 6 weeks from surgery. Upon the end of the immobilization period, mechanotherapy was prescribed with using the “Artromot” device (Germany), as well as following the rehabilitation protocol for injured muscles of the described group [20, 21].

The patient was monitored remotely (photographic depiction of the exercises done by the patient, according to the rehabilitation protocol, 12 weeks after surgery, is shown in Fig. 4).

 

Fig. 4. The patient performing exercises from the recommended rehabilitation protocol [20, 21] 12 weeks after surgery (а–d).

 

Three months after surgery, a repeat assessment of the range of motion, the sum of LEFS scale points and the assessment of the muscle stamina by holding the fully extended leg above the contact surface (when lying prone). Based on the examination results, the following motion amplitude was achieved for the right hip joint: flexion/extension 125/0/15, abduction/adduction 55/0/15, internal/external rotation 35/0/30; the right knee joint — 135/0/0; the ankle joint — 45/0/5. The sum of the LEFS scale points was 62, the duration of holding the extended limb was 1 minute 43 seconds, which reflects the positive clinical-functional result of the conducted treatment.

A follow-up MRI of the right hip was also performed: the myotenodesis was successful (Fig. 5).

 

Fig. 5. Magnetic resonance imaging of the soft tissues in the right thigh 3 months after surgery (axial and frontal slices): а — the myotenodesis is consistent, the axial slice shows a fused conglomerate consisting of the sutured SM tendon (round black dot), the proximal belly of SM and the belly of ST; b — separation between the SM and the ST muscle bellies; c — all the three muscle bellies are clearly visible. ST (m. semitendinosus) — semitendinosus muscle; SM (m. semimembranosus) — semimembranosus muscle; Biceps^LH (m. biceps femoris) — the long head of the biceps femoris muscle.

 

DISCUSSION

The choice of treatment tactics, according to the literature data, differs for the professional athletes and for the amateur athletes. For the professional athletes, just as for the individuals with high requirements in terms of physical loads and time-sensitive return to the professional sports activities, the preferable option is the surgical treatment, and here the following factors matter: the male sex, the isolated injury of the semimembranous muscle, the proximal rupture of the free tendon [22]. The amateur athletes can be treated using the conservative therapy. The proposed rehabilitation program includes three phases:

• reduction of scarring, minimization of swelling;
• increasing intensity and range of motions, eccentric exercises;
• addition of specific movements, characteristic for the specific type of sports [23].

It is worth noting that the application of topical injections with using both the glucocorticoids, and the orthobiologic treatments (platelet-rich plasma, PRP), remains controversial by its results [7]. It is also worth noting that, during the analysis of literature, there were no detected research works describing the tactic algorithm depending on the status of the patient (age, requirements in terms of physical activity, duration of injury) with the justification of its efficiency.

According to the opinion of some authors, the indication for surgical treatment of the proximal avulsions of the tendons of the SM, ST and Biceps^LH muscles include the detachment of all the three tendons; the avulsion of the two tendons with the retraction exceeding 2 cm; the avulsion fracture with the dislocation, as well as the presence of chronic pain syndrome with functional abnormalities [24, 25].

In the acute period following injury, the treatment presents no difficulties, however, some cases report the late diagnostics of the injury, and in some cases the injury is even missed upon the initial admission of the patient to the specialist [26, 27], just like it was in the presented observation. The better functional outcomes and the rapid returning to daily activities are observed with early treatment within up to 6 weeks, however, the total satisfaction of the patient is still comparable to the delayed recovery and reconstruction [26, 28].

J.D. Harris et al. [26] in their systematic review have compared the surgical and the conservative therapy, as well as the clinical results in the acute and the neglected cases: higher results were reported in patients presenting within the first several days after injury and undergoing the surgical intervention. It was also reported that early post-injury rehabilitation allows for technically simpler surgery with lesser dimensions of the access incisions, with the mobilization of the tendon and with the absence of the need for the sciatic nerve neurolysis. In cases of neglected ruptures with the significant retraction of the tendon, requiring the mobilization of the muscle belly and the neurolysis of the sciatic nerve, the wider access is needed [19, 26].

Some authors consider that, if the tendon retraction exceeds 5 cm, for better restoring the functions, the reconstructive intervention is needed with using various tendon transplants with further anchor fixation to the ischial tuberosity [29–31].

There are various variations in surgical techniques and tendon material selection. In our patient, a total of 3 years have passed from the moment of injury, there was a substantial retraction (9 cm) with the formation of adhesions around the sciatic nerve and its branches, with this, the patient had no high functional requirements related to returning to professional sports activities. For this reason, we skipped the reconstructive-plastic intervention, also taking into consideration the extent of the defect. Following the treatment, patient and his immediate family had no complaints and were satisfied with the result. Based on this, it can be assumed that in cases of the neglected injury with substantial retraction of one of the flexor muscles in the shin and with the relative integrity of the other (stipulating that the patient is not planning to return to the professional sports activities), performing the myotenodesis can be considered an effective variant of surgical treatment.

Prognosis

The authors note that the provided publication has the limitations characteristic for clinical case descriptions, also related to the short follow-up period after the conducted intervention (3 months).

CONCLUSION

Thus, when consulting the patients with a suspected sports injury, the important aspect is the verification of the possible soft-tissue damage, in particular, the tendons and the muscular structures, which is decisive in the treatment tactics.

The clinical case we present may be of practical interest to traumatologists-orthopedists and for the sports medicine specialists, of which the field of professional interest includes the pediatric trauma care and orthopedics.

ADDITIONAL INFORMATION

Author contributions: S.A. Rokhoev, treatment, manuscript writing; V.I. Zorin, study concept and design, editing; K.A. Kartavenko, treatment, editing; S.Yu. Semenov, case report, manuscript preparation; S.A. Lukyanov, literature and data analysis. Thereby, all authors provided approval of the version to be published and agree to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Consent for publication: The authors received written informed voluntary consent from the patient to publish personal data, including photographs (with the face covered), in a scientific journal, including its electronic version (signed on 2025 March 17). The volume of published data was agreed upon with the patient.

Funding source: The study was carried out within the framework of the state assignment, the research topic “Monitoring the state of the musculoskeletal system in children who play sports and do not play sports, based on a comprehensive assessment of the level of motor activity, clinical imaging, biomechanical parameters, as well as biomarkers of the state of bone and muscle tissue” (registration number 124020400015-5).

Disclosure of interests: The authors declare that they have no competing interests.

Statement of originality: The authors did not use previously published information (text, illustrations, data) while conducting this work.

Data availability statement: The editorial policy regarding data sharing does not apply to this work.

Generative AI: Generative AI technologies were not used for this article creation.

About the authors

Saigidula A. Rokhoev

H. Turner National Medical Research Center for Children’s Orthopedics and Trauma Surgery

Author for correspondence.
Email: 09saga@mail.ru
ORCID iD: 0000-0003-4369-9619
SPIN-code: 4366-8309
Russian Federation, Saint Petersburg

Vyacheslav Ivanovich Zorin

H. Turner National Medical Research Center for Children’s Orthopedics and Trauma Surgery; North-Western State Medical University named after I.I. Mechnikov

Email: zoringlu@yandex.ru
ORCID iD: 0000-0002-9712-5509
SPIN-code: 4651-8232

MD, PhD

Russian Federation, Saint Petersburg; Saint Petersburg

Kirill Aleksandrovich Kartavenko

H. Turner National Medical Research Center for Children’s Orthopedics and Trauma Surgery

Email: med-kart@yandex.ru
ORCID iD: 0000-0002-6112-3309
SPIN-code: 5341-4492

MD, PhD

Russian Federation, Saint Petersburg

Sergey Yu. Semenov

H. Turner National Medical Research Center for Children’s Orthopedics and Trauma Surgery

Email: sergey2810@yandex.ru
ORCID iD: 0000-0002-7743-2050
SPIN-code: 8093-3924

MD, PhD

Russian Federation, Saint Petersburg

Sergey Andreevich Lukyanov

H. Turner National Medical Research Center for Children’s Orthopedics and Trauma Surgery

Email: Sergey.lukyanov95@yandex.ru
ORCID iD: 0000-0002-8278-7032
SPIN-code: 3684-5167

MD, PhD

Russian Federation, Saint Petersburg

References

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