Snapping Hamstrings

Snapping Hamstrings

Case Presentations: 

Case 1:   A 68 year-old woman presented with a 1-month history of right medial knee pain following a minor mechanism of stepping on uneven ground. She had unexpected intermittent episodes of sharp knee pain lasting seconds with walking and certain movements. There were no mechanical symptoms or swelling. On examination, she had subluxation of her medial hamstring with passive flexion and extension. There was mild tenderness to the pes anserine tendons. There were no findings indicating meniscal or ligamentous pathology.

Case 2:  35 year old man presents with a several year history of lateral knee snapping following cycling 2 hours/day.   There was no report of a specific injury.  Patient significantly limited with activity including cycling and running because of the snapping, only asymptomatic with inactivity.  Able to reproduce snapping with active flexion and extension of knee.  Taping was not effective for this patient.  Remainder of knee examination was normal.

Introduction:  

Medial knee snapping occurs uncommonly and is infrequently described in literature. Several case reports showed that soft-tissue structures, most commonly the semimembranosus and gracilis tendons (1-4), were responsible for this snapping phenomenon.  Lateral knee snapping is also uncommon, biceps femoris tendon can snap over the fibular head when actively being flexed or extended.

Etiology: 

Medial:  Two studies made speculations as to the underlying cause of this condition. One performed an anatomical study where the investigators found that the affected gracilis tendon was aberrantly located anterior to the posterior edge of the medial femoral condyle (1). Another group of investigators postulated that overloading of the anterior aspect of the knee in jumping sports combined with knee hyperextension increase the force of displacement on semitendinosus and gracilis, causing them to slip out of the shallow groove. This may be accentuated by faulty protective mechanism involving the accessory tendinous expansions of the semitendinosus. These accessory bands prevent the tendon from slipping out and may be less effective the more distally placed they are due to a longer lever arm (2).

Lateral:  18 cases were identified in the literature with three different pathologies.  1) Exotoses, or abnormal fibular head (which anterior portion snaps over) 2) Anatomilcal anomaly – fibular insertion located more anteriorly on fibular head OR abnormal tibial insertion.  3) Partial tears of distal tendons.   The majority of cases occurred in males (15/18), and in the absence of injury.  In 2 of the 18 cases occurred after injury – 2 soccer.

Differential Diagnosis:

Medial:  Medial meniscal tear, Pelligrini stieda lesion, rheumatoid nodules, underlying osteochondroma, osteoarthritis.

Lateral:
Lateral meniscal tears, iliotibial band syndrome, proximal tibiofibular joint instability, popliteus, peroneal nerve compression/neuritis, lateral discoid meniscus, rheumatoid nodules, plica, osteochnodroma, osteoarthritis.(6)

Clinical Presentation: 

Snapping medial hamstrings typically occur in patient anywhere from the teens to the 30’s, however older patients may also have these symptoms. Symptoms were knee pain and posteromedial snapping with movements involving flexion and extension of the knee. Onset was insidious with no clear preceding trauma. The symptom duration reported was anywhere from 6 months to 17 years on presentation (1-5).   As with other snapping tendon syndromes, it they typically occur with a repetitive exercise where the joint is flexed and extended.   Our first case eludes to the the potential contributing factor of muscle atrophy.

Lateral snapping hamstrings, in cases identified in literature, occurred between the ages of 15 and 44, in either active patients with history of running, cycling, and/or deep squatting or inactive patients.  The condition is occasionally painful, but pain-free snapping is also reported.  The snapping often leads the athlete to discontinuing their afffected activity.

Physical Examination:  

Positive physical findings described include palpable and visible snapping observed at the posteromedial aspect at 30 degrees of flexion during active and passive flexion/extension (1,4), and tenderness to the posteromedial area (4).

Snapping Biceps Femoris:

Ultrasound of Tendon snapping:

Diagnosis:  

Medial:  Some cases made the diagnosis primarily based on history and physical examination, in the absence of diagnostic imaging findings (1,5). Two papers diagnosed this condition with dynamic ultrasound and advocated for the use of this modality in this context (2,4). One showed that the gracilis and semitendinosus tendons were rolling/snapping over the semimembranosus at 30 degrees of flexion as the knee was moved from full flexion to extension and vice versa (4). Another study showed anterior subluxation of the semitendinosus and gracilis tendons over the semimembranosus insertion at the posteromedial corner of the tibia during active terminal extension (2).

Lateral:  Clinically the snapping hamstring can be identified on inspection with active flexion and extension of the knee between 70 and 120 degrees of knee flexion (9, 11, 14, 16, 20)

Investigations:

Ultrasound – will demonstrated subluxation, may identify tear, or hyperemia in affected tendon.
Xray – may identify increased fibular head size

MRI – can be used to rule out: lateral meniscal tear, discoid meniscus, partial biceps femoris tears, anomalous fibular head/exostosis, popliteus injury

Management:  

Medial:  All case reports reviewed were published in orthopedics literature with subsequent discussion on surgical management. Various techniques including resection or release of the tendons involved were described with positive outcomes reported (2-5).

Lateral:  Conservative treatments included hamstring stretching, taping/thigh straps, non-steroidal anti-inflammatories and modification of intensity of activity.  The conservative treatments were often described to be unsuccessful.  Surgical interventions included partial resection of fibular head, relocation (either by tunnel or reattachment) of biceps femoris tendon insertion, anterior band resection, anomalous tibial insertion resection.  Peroneal nerve protection is essential for surgical cases.

Authors Dr. Su Fei Yu  and Dr. Neil Dilworth (Feb 5, 2019 PR WC)

References 

1. Seino D, Nakayama H, Imamura F, Moro-oka T, Yoshiya S. Snapping knee caused by the gracilis tendon: A case report with an anatomical study. Asia-Pacific Journal of Sports Medicine, Arthroscopy, Rehabilitation and Technology. 2014;1(2):77-80.
2. Karataglis D, Papadopoulos P, Fotiadou A, Christodoulou A. Snapping knee syndrome in an athlete caused by the semitendinosus and gracilis tendons. A case report. The Knee. 2008;15(2):151-154.
3. Geeslin A, LaPrade R. Surgical treatment of snapping medial hamstring tendons. Knee Surgery, Sports Traumatology, Arthroscopy. 2010;18(9):1294-1296.
4. Bollen S, Arvinte D. Snapping pes syndrome. The Journal of Bone and Joint Surgery British volume. 2008;90-B(3):334-335.
5. von Dercks N, Theopold J, Marquass B, Josten C, Hepp P. Snapping knee syndrome caused by semitendinosus and semimembranosus tendons. A case report. The Knee. 2016;23(6):1168-1171.
6. Ernat JJ1, Galvin JW. Snapping Biceps Femoris Tendon. Am J Orthop (Belle Mead NJ). 2018 Jul;47(7). doi: 10.12788/ajo.2018.0055.
   7 Fung DA1, Frey S, Markbreiter L.  Bilateral symptomatic snapping biceps femoris tendon due to fibular exostosis.  J Knee Surg. 2008 Jan;21(1):55-7.8 McNulty M1, Carreau J2, Hendrickson N2, Bollier M2.  Case Report: Snapping Biceps Femoris Tendon Due to Abnormal Fibular Morphology.  Iowa Orthop J. 2017;37:81-84. 9 Bansal R, Taylor C, Pimpalnerkar AL. Snapping knee: an unusual biceps femoris tendon injury. Knee. 2005;12(6):458-460.10 Mirchandani M, Gandhi P, Cai P. Poster 175 bilateral symptomatic snapping knee from biceps femoris tendon subluxation–an atypical cause of bilateral knee pain: a case report. PM R. 2016;8(9S):S218-S219.11 Date H, Hayakawa K, Yamada H. Snapping knee due to the biceps femoris tendon treated with repositioning of the anomalous tibial insertion. Knee Surg Sports Traumatol Arthrosc. 2012;20(8):1581-1583.12 Vavalle G, Capozzi M. Symptomatic snapping knee from biceps femoris tendon subluxation: an unusual case of lateral pain in a marathon runner. J Orthop Traumatol. 2010;11(4):263-266.

   13 Bernhardson AS, LaPrade RF. Snapping biceps femoris tendon treated with an anatomic repair. Knee Surg Sports Traumatol Arthrosc. 2010;18(8):1110-1112.

   14 Guillin R, Mendoza-Ruiz JJ, Moser T, Ropars M, Duvauferrier R, Cardinal E. Snapping biceps femoris tendon: a dynamic real-time sonographic evaluation. J Clin Ultrasound. 2010;38(8):435-437.

   15. Bagchi K, Grelsamer RP. Partial fibular head resection for bilateral snapping biceps femoris tendon. Orthopedics. 2003;26(11):1147-1149.
   16. Hernandez JA, Rius M. Noonan KJ. Snapping knee from anomalous biceps femoris tendon insertion: a case report. Iowa Orthop J. 1996;16:161-163.
   17. Kissenberth MJ, Wilckens JH. The snapping biceps femoris tendon. Am J Knee Surg. 2000;13(1):25-28.
   18. Lokiec F, Velkes S, Schindler A, Pritsch M. The snapping biceps femoris syndrome. Clin Orthop Relat Res. 1992;(283):205-206.
   19. Kristensen G, Nielsen K, Blyme PJ. Snapping knee from biceps femoris tendon. A case report. Acta Orthop Scand. 1989;60(5):621.
   20. Bach BR Jr1, Minihane K. Subluxating biceps femoris tendon: an unusual case of lateral knee pain in a soccer athlete. A case report. Am J Sports Med. 2001 Jan-Feb;29(1):93-5.
   21. GuenounP. ChampsaurJ.-M. CoudreuseT. CucuruloA. LagierT. Le Corroller  A symptomatic anomalous biceps femoris tendon insertion Diagnostic and Interventional Imaging:  January 2016Volume, 97(Issue1)Page, p.113To-115