ACL reco. hamstring graft results is hamstring tendonitis?

[arniar]

Hello

Please help me if you can. I have been off running for almost 1 1/2 years. That makes a dedicated runner like me very sad.

I had an ACL reconstruction surgery nearly 11 months ago, with hamstring autograft. My knee seems to be ok, as shown by post-op MRI.

The problem lies in the graft donor area. The hamstring was very tight for long time, causing knee problems. But with proper massage and streching the knee has gotten better. However, there are no further improvements and the hamstring gets tight after exercising. I need to massage several times each day. The hamstring tendon is swollen all the time. I can feel two knots in the muscle. I cannot bend the knee fully. I feel numb in my sole. The problem affects my walking.

This may sound like hamstring tendonitis. Can ACL with hamstring graft cause hamstring tendonitis?

With hope of getting help,
Arni

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[Canuck Physio]

Hello,

I doubt that you have hamstrings tendonitis, unless you have been completing repeptive and strenuous or high load training recently. but post op?

It is more than likely that you still have shortening of the hamstrings. If not shortening some form of myofascial issue/scarring.

Massage, although useful, would not necessarily enhance collagen alignment and fibroblast production like a good blast of Physiotherapy!

also, how is your stability? Foot position post op? Or most importantly flexibility! Hamstrings are a significant stabilizer and without training it is unknown if the 'exercise' (which one) that you are doing is exacerbateing problems.

[arniar]

Hi again

So far as I can tell, I think my flexibility and balance is normal. Also my foot position.

I am also very sore in the particular hamstring muscle close to the hips(the middle one, the others are without problems). I think I can also feel a bump up there. That would be the 3rd bump in the muscle I know of

The muscle gets very tight after long walking or 10 minutes jogging. So I am rather no exercising except biking.

I am working on getting a new physiotherapist. Had 2 therapists so far with no success.

[arniar]

Furthermore,

I feel tight in the morning after sleep, and after sitting for a prolonged period. There is no pain in the muscle, but when the hamstring gets very tight I start to feel pain in my anterior knee.

I do stretching and massaging several times each day, and sleep with a heating pad fixed on the hamstring.

[arniar]

My hamstring becomes tense when I bend the knee. It is like I am fighting against the muscle.

What could be causing this?

[arniar]

It turned out to be a failed regeneration of the harvested Semitendinosus tendon. The muscle is loose and shortened.

I dont know what can be done to fix this. If anyone knows something about this condition, please inform me.

I have an appointment with an orthopedist late this month.

[Physio Dace]

Arnier,

Can I ask how you came to conclusion that it was failed regeneration of the semitendinosus? Did you have investigations or was it a clinical diagnosis?

From reading the posts up until the last one I was swaying more towards a neural tension disorder of the sciatic nerve (tibial branch perhaps) - this may explain the distal foot symptoms and local. However without more info you have to consider the hamstring to be the most likely source - so good luck with your rehab and ortho review.

[arniar]

Hi Dace

I met an orthopaedist who told me this.

The semitendinosus muscle is very stiff at all times. And I can move it a bit to the sides. No stretching or massaging has helped.

A surgery seems to be the only option.

I am wondering if improper rest after the acl reconstruction operation could have played a role in this. Only 5 days after the operation, I was back to (office) work. However, I read it takes 6 weeks for the harvested tendon to grow.

Thanks for your good wishes,
Arni

[physiobob]

Yep the hamstring tendon graft nearly always causes hamstring problems for at least 12-18 months post the surgery. It is pretty basic 'blind' carpentry when harvesting the tendon and everyones anatomy and recuperation ability is different. That said I myself would rather than than a patella tendinitis following a graft from that region.

You are not alone in your issue. I see this more often than not which perhaps means the surgeons should look at the way they make the harvest. As for the muscle it sounds like it is reacting in a normal way to excessive leads placed upon it to soon.

Suggest working with a good remedial massage therapist and PT to work on a graded approach to your return to activity. This plan make take another 6 months. Of course if a scan has shown a problem in the tendon then perhaps a surgical investigation and clean up might be useful as well.

Good luck.

[arniar]

Thanks Physiobob

What really surprises me is that you are saying that this is common. That makes me feel better, because it'd help me to find a way out of this.

I am actually feeling better now than two months ago. I can bend my knee and often without hearing any clicks in the knee. But I cannnot jog for more than one minute as a am quite unstable. I am biking nearly everyday in the gym for 30 minutes+.

Today I will see another orthopaedist.

I found this article describing a case very similar or same as mine,

Failed regrowth of the harvested semitendinosus tendon: a rare complication of tendon harvest after anterior cruciate ligament reconstruction.

[arniar]

I went to see a doctor last Monday. I gave him my MRI images since July. He couldn't see anything abnormal there. Also, he concluded that my knee is doing fine and the new ligament is firm. That is good news.

But regarding my hamstring, he was quite surprised to see how tight the Semitendinosus really is. He booked an ultrasonography examination and I will need to wait until January for that. He could not diagnose my problem, and said this was a rare case.

I also met a physiotherapist. His advice to me was to strengthen the hamstring since it is visible smaller on the operated leg than the other. I should take heavy weight, about 9-10 repititions, all out.

[arniar]

Well folks, everything turned out to look normal in the sonography, and so does mri. My condition is not improving, 15 months post acl reconstruction with hamstring graft.

The Semitendinosus seems to be in a state termed "chronic spasm" and the hamstring has only 40-50% of full strength. Strength training has not worked, and the muscle hurts if I take too much weight. I feel a little numbness below the knee. I cannot walk normally.

From what I have read, I believe this to be a case of extensive scar tissue formation or muscle adhesion. The muscle mobility is very limited. I would love to hear your opinion.

Next appointment with my doctor is next week, and that is a very important day in my life.

[wozzie]

I was just wondering how everything was going now and if anyone could help me?

I had my ACL and a tear to my medial meniscus repaired last October now - I am now 6 months down the line and have been having significant hamstring problems since Christmas.

Basically Oct - Christmas was spent on a limited physio programme due to the meniscus repair - no squats, no pressure on a bent knee beyond 30 degrees etc.... Then after Christmas I reached my 3 month point and we began to introduce the squats and single leg work.

However since that point I have had problems with my hamstring. To start with I thought that I had just overdone the exercises a little too soon - as I had such tightness post exercise and cramping on anything like hamstring curls that after a session in the ACL class at physio I struggled to do anything the next day at all and even struggled to walk without a limp at times.

Diagnosis 1 - muscle imbalance between quads and hamstrings. Suggested that we adjusted the exercises.

However this did not improved things - in fact what I hadn't realised was that after exercise I was getting bruising appear in a vertical line up the centre of my hamstring from my knee (same place as I had bruising post surgery but this had cleared up before Christmas) and a large lump had formed.

Diagnosis 2 - scar tissue that needed breaking down. So on top of my twice weekly acl physio classes I now began having massages to break down the scar tissue.

However whilst the scar tissue and lump significantly improved after massage, exercise irritated it and caused it to build again. So we removed the exercises that irritated the most - single leg squats, lunges, dip steps, running etc... However it couldn't stay like this forever so we tried to gradually reintroduce exercises. By this point we were at 4-5 months. I got to see the surgeon during this time and he was at a loss as to why and what - he tested my hampstring strength but the whole lot went straight into spasm. He referred me to have an ultra sound but I am still waiting for this.

In the meantime - Diagnosis 3 - nerve tightness and resulting neuro stretches - but still the hamstring is a problem.

I am now 6 months in, and over the last couple of weeks have tried to just push myself forward through accepting the pain and discomfort and trying to do the exercises - but to no avail. I work in sport and have always played sport - so the lack of recovery has really started to get me down. Now the physio is now back to the muscle imbalance diagnosis - lower back perhaps this time so a new lot of exercises.

In terms of ongoing symptoms - hamstring cramps very easily doing curl type exercises, numbness where scar tissue lump continues to build on lower hamstring, recurring bruising (although significantly lighter that in the past), general throbbing of the hamstring whilst at rest, nagging right up to my bottom, lack of strength depsite daily exercise (the squats are not getting any easier) and the same exercise still continue to aggrivate it - single leg squats, dip steps, and running for more than 1 minute.

Does anyone have any suggestions? Will the ultra sound find out what is wrong? Will it just get better over time?

Any help gratefully received.

[arniar]

Hello

This sounds similar to my problem. 17 months after the ACL reconstruction with hamstring graft, I am still having the same problems and 1 year ago. Extremely tight hamstring and muscle spasm even when exercising lightly. Swelling and loss of sensation in the foot. This ACL reconstruction has destroyed my life.

MRI has shown degenerated Semitendinosus muscle. I have a bulge in the hamstring when I tense the muscle. Either caused by failed regeneration of the Semitendinosus tendon or nerve problem. Probably the tendon is damaged. Whatever the problem is, I want this fixed. I have met a number of orthopedists and no one has seen this before. Next week I will be meeting some of the best orthopedist in Denmark. If you like to know how it goes, just ask me to post it here.

Arni Richard
[email protected]

[wozzie]

Sorry to hear that you are no further forward and so long after surgery too. I would be grateful to hear how your appointment goes next week. I'm just finding that the physiotherapists are just unsure of what is going on as they haven't seen this before - they are trying and giving a lot of time, but we are still not any nearer.

At the moment I am at the physio department 3-5 times per week and I am exercising (cycling and swimming mostly) in a bid to get better. I have done everything as instructed pre and post op, so it's just frustrating. And I don't think I have been asking enough questions or demanding enough answers.

Thanks for sharing your experiences.

[arniar]

Is your harvested muscle tight at all times? Is there any visible bulge when you tense the muscle or flex the knee? Can you sense that the harvested muscle (presumable Semitendinosus) is smaller than in the other leg?

The lump you mentioned could result from muscle adhesion.

I suspect my condition to be a bad case of that described in this paper:

Failed regrowth of the harvested semitendinosus tendon: a rare complication of tendon harvest after anterior cruciate ligament reconstruction.

My advice to you is to find an excellent orthopaedist and get MRI on the thigh as soon as possible.

I had an ultrasould sonography which did not reveal anything. Just waste of time for me.

For the last months I have been focusing on stability exercises, because the knee will be unstable with so weak hamstring. The stability has got a little better, but not good enough.

[arniar]

Complete rupture of a hamstring muscle.

reconstructed acl was incorrectly inserted (as revealed in a surgery last Wednesday)

Going to file a lawsuit.

[wozzie]

Really sorry to hear that things are not good with your hamstring - but some answers at long last it seems!

I have now had my ultrasound and it shows a mass of musle which shouldn't be there in this particular place, but no damage to it and no apparent reason why it is still going into spasm.

Now waiting for consultants appointment.

In the meantime - physios have tried and now ruled out an inbalance in my back and this morning suggested it could be scar tissue that is causing it all when I saw a different physio.

So still playing a waiting game.

[arniar]

In my case, the muscle tore from the upside, not from the downside. This had confused many who tried to diagnose the problem.

I am being told that it is too late to attach the muscle. But I wont give up and will meet another doctor on Wednesday who has actually performed a later repair of a completely ruptured hamstring.

I think the reason for the torn muscle is that my physiotherapist made me do an exercise immediately after the operation which I should not have done. The exercise is seated leg curl, and should not be done for the first two months after operation in the case of hamstring graft.

My doctor says I should be able to run with a torn muscle, by strengthening the adjoining muscles. I really hope he is right.

Your case sounds like a rupture. If that is the case, it must be repaired as soon as possible.

[wozzie]

I have had an ultrasound - do you think I should be pushing for an MRI too? (Although I'm not liking my chances)

Was it only surgery that finally solved the unknown in your case?

I am just desperate to know what is going on and then work to get it fixed, but the system is just not getting me anywhere fast.

[arniar]

I gave up on the public health care and went for a private hospital to find the best known orthopedist surgeon in Denmark. In just few minutes he found out that the muscle was ruptured from the upside, without looking at the MRI at all.

I did not have a surgery to find this out. However, a knee surgery revealed that the acl was wrongly inserted.

In your case, you should really demand MRI.

If there is a tendon rupture, the muscle is loose at the other end.

If you can consult a respected orthopedist who works mostly with sports people, you should definitely do that even though it will cost you some money, that is if you can afford it.

Best of luck

[arniar]

I have got yet another diagnosis and now it is confirmed. My semitendinosus tendon did not grow back. I blame it on hamstring exercises that my physio made me do only one week postoperatively and onwards. It involved hamstring curls with weights.

This came as a shock to me even though the doctors tell me that I will be able to run without this muscle. I really want the muscle fixed. I wonder if prolotherapy can help. Otherwise I may consider tendon reconstruction with an allograft.

I need to work on the hamstring now since it is very weak. I experience spasms in the semitendinosus in hamstring curls even when only using minimum possible weight.

All advices and information about my considerations are well appreciated. Also some tips on hamstring exercises. I dont know whether I should work more on the weak hamstring than the healthy one, or keep it balance. Should I do training everyday, or more intensive training 3-4 times a week?

[utahacl]

It's incredible to read that others have gone through exactly what I have! Thank you for your post arniar. I thought I was the only one that has had this rare complication. I have the exact same problem with my hamstring and I've been dealing with it for 14 years! I had an ACL reconstruction in 1996 where the surgeon harvested the gracilis and semitendinosus muscles, and a month after the surgery I had extremely painful cramping in the back of my leg. There was and still is a bulge closer to the knee, and the doctors could never figure out why the bulge wasn't up near my pelvis. They figured if the problem was that the tendon of the hamstring never regenerated, then when the hamstring contracts it should pull upwards and form a bulge there, not down by the knee.

I went through 3 different MRI's to figure out what was going on, and it was obvious that my injured leg was very different from my normal leg, but none of the doctors had a clear idea why. They proposed various ideas, and suggested different treatments including just cutting open the back of my leg and having a look. One of the surgeons said he thought it would make a great paper in a journal because he was certain nobody else had gone through what I have.

In the end, I tried lots of physical therapy and while the pain is not as bad as it was, it's never gone away and my leg has never been the same. If I do dead lifts or squats, the hamstring in the back of my right leg immediately cramps up. I decided not to do another surgery because none of the orthopedic surgeons had a clear idea of what was best to do. One doctor thought the problem was due to the release of the fascia covering the hamstrings during the operation, and another thought I actually ruptured my semimembranosus training after the surgery. The doctors said they didn't think it could be the semitendinosus muscle causing the problem because how could it rupture near the pelvis when the lower tendon was cut by the surgery? It's interesting that the doctors say that's what's happened to you arniar.

Has anyone ever been able to figure out a treatment for this problem that was successful? I would love to finally feel normal again after all this time.

[arniar]

My semitendinosus muscle ruptured from the pelvis due to massive degeneration of the muscle in the following of the harvesting. The doctors say it is probably caused by either too aggressive harvesting or physical therapy after training. I described my physical therapy that I got and they agree that the training was way too harsh.

A good doctor should be able to diagnose muscle semitendinosus rupture by using his fingers and ultrasound sonography. If the muscle is ruptured from the pelvis then it should be little loose there when you stretch the muscle and also some atrophy should be visible at that place.

Later on my gracilis muscle ruptured, first from the pelvis and then from knee. I have had a total of 5 successful operations to correct the mistakes from the first surgery. My doctors are Uffe Jorgensen, Parkens Privathospital, Copenhagen , Denmark and Sakari Orava, Mehilainen, Turku, Finland.

I advise you to find a world class doctor who can help you.

[dawnstan]

Hi Arniar and Utahacl,


I'm experiencing many of the symptoms you both described. I had ACL reconstruction with hamstring graft in November 2009. I was faithful in physio, did everything I was instructed to do and bounced back more quickly than most people in every way except hamstrings. Therapist didn't get it (or wouldn't listen) as I tried explaining ... pretty much everything you explained with limits, spasms, etc., So the result is (9 months later)...I have an abnormally weak hamstirng despite all the exercise I've been doing. The curls always sent the muscle into spasm...i felt like I didn't know my strength potential because these severe spasms prevented me from doing enough reps (even very light weight). Also, I can't curl as high as the other leg... it's as if something's missing - now i understand it's too short. I'm stretching the hams and calves so often (always feels necessary) that it's like they're overstretched...or like what should be stretching isn't there...thus too easy. Maybe that sounds too weird and it's my isolated case in terms of stretching.
Anyway, today my surgeon suggested "the tendon didn't grow back" and said he had never seen this before. He said I might just have to live with this condition, no further physio or surgery could help. I pushed - desperate to hear that there might be hope for improvement (I really miss my sports, and my knee pain is getting worse) and he said he would talk to some colleagues for other opinions / experiences. He did say that weak hamstring will cause knee pain.

I think I should ask for an MRI ??

Thanks, and I hope you're both doing better these days.
Dawn.