Hamstring Origin Percutaneous Needle Tenotomy

Other Names

Illustration of the hamstring muscles

• Hamstring Origin Percutaneous Needle Tenotomy
• Hamstring Needle Tenotomy

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Background

Key Points

• Needle: 22 gauge, 3.5 inch
• Transducer: High frequency linear or curvilinear
• Can be hard to identify, patient positioning is key

Anatomy of the Hamstring Muscle Group

• Muscles: semimembranosus, semitendinosus, biceps femoris
• Diarthrodial and work to extend hip, flex the knee
• All of them originate from the ischial tuberosity
• Note: short head of biceps femoris originates at the linea aspera of the femur

Palpation vs Ultrasound Guidance

• Palpation guided approach has been described, accuracy is not known
• We strong encourage this procedure to be performed with ultrasound guidance

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Indications

• Proximal Hamstring Tendinopathy

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Contraindications

• Absolute
  • Anaphylaxis to injectates
  • Overlying cellulitis, skin lesion or systemic infection
• Relative
  • Can be treated with less invasive means
  • Muscle tear or rupture
  • Hyperglycemia or poorly controlled diabetes
  • Lack of symptom improvement with previous injection

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Procedure

Long axis, in plane needle and probe position with the patient in the sideling position

Long axis, in plane ultrasound view showing needle (white arrows), gluteus maximus (GM) and ischial tuberosity (IT)

Short axis, in plane needle and probe position

Equipment

• Sterile prep (i.e. chloraprep, chlorhexidine, iodine, etc)
• Gloves
• Needle: typically 22 gauge, 3.5 inch
• Syringe: 5-10 mL
• Gauze
• Ethyl Chloride
• Bandage
• Injectate
  • Local anesthetic
  • Corticosteroid
• Sterile probe cover

Ultrasound Findings

• Finding the proximal hamstring
  • Long axis using a high frequency linear or curvilinear transducer
  • Depth of 3 to 6 cm
• Tendinopathy findings
  • Thickened tendons
  • Hypoechoic areas
  • Loss of normal fibrillar architecture
  • Hyperechoic foci of calcifications
  • Partial, degenerative tears

Technique: Long Axis, In Plane

• Patient Position
  • Prone
  • Alternative position: lateral decubitus, affected side up, hip and knee flexed
• Transducer position
  • Long axis to hamstring tendon complex
• Needle Approach/ Orientation
  • In plane
  • Distal to proximal or proximal to distal
• Target
  • Hamstring tendon origin
• Pearls and Pitfalls
  • Must identify and avoid sciatic nerve

Technique: Short axis, In Plane

• Patient Position
  • Prone
• Transducer position
  • Short axis to hamstring tendon complex
• Needle Approach/ Orientation
  • In plane
  • Lateral to medial
• Target
  • Hamstring tendon origin
• Pearls and Pitfalls
  • Must identify and avoid sciatic nerve

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Aftercare

• No major restrictions in most cases
• Can augment with ice, NSAIDS

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Complications

• Sciatic Nerve Injury
  • May inadvertently regionally block the sciatic nerve which will resolve as anesthetic wears off
  • Can also fenestrate sciatic nerve if not careful during procedure
  • Very important to identify during pre-procedure sonogram
• Skin: Subcutaneous fat atrophy, skin atrophy, skin depigmentation
• Painful local reaction
• Infection
• Hyperglycemia
• Tendon, nerve or blood vessel injury

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See Also

• Procedures Main
• Ultrasound Main
• Hip Pain Main

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