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The SISM Blog

Paul O’Connell – Acute Hamstring Avulsion Injury

By SISM Clinic | In SISM Blog | on October 17, 2015

The severe hamstring injury sustained by Ireland rugby captain Paul O’Connell has the nation talking this past week. The graphic and harrowing extent of his injury was relayed on live television across the world. So what exactly is this potentially career-ending injury? A National Football League team published injury data for their team during pre-season training camp from 1998-2007 (Feeley et al. 2008). Hamstring strains were the second most common injury, only surpassed by “knee sprains”. Screen Shot 2015-10-17 at 10.50.36Numerous studies have shown that hamstring strains are one of the most common injuries in sprinting sports, soccer, rugby and Australian Rules football (Gabbe et al. 2004). Much less common, but most often much more severe, are the hamstring injuries involving complete avulsion of the hamstring complex off the ischial tuberosity. When this occurs a large amount of bleeding (hematoma) will form in the back of the thigh and the tendon will move down the thigh, retracting away from the ischial tuberosity. Almost all injuries occur from a slip or a fall that creates forceful hip flexion with simultaneous knee extension, many of these during sporting activities. These complete avulsions result in significant or complete loss of hamstring function depending on how many of the tendons are avulsed. This can lead to poor leg control and difficulty even walking. Because of the significant structural damage and resultant disability, these injuries are often treated with open surgical repair (Wood et al. 2008). Screen Shot 2015-10-17 at 10.50.47After injury, the main question of the athlete, coaching staff and press is: when can they return to play? During the tendon avulsion repair, hamstring muscles are pulled back to its normal attachment. Your surgeon cuts away any scar tissue from the hamstring tendon and then the tendon is reattached to the bone using staples or stitches. If there is a complete tear within the muscle, the torn ends are reattached using stitches. After surgery, you may need to use crutches and a brace to protect and keep your hamstring muscle in relaxed position. Rehabilitation involves initial gentle stretching exercises in order to restore normal function. Rehabilitation period of at least 6 to 9 months may be needed before returning to athletic activities. (Sherry and Best, 2004)


The University of Wisconsin Sports Medicine and Rehabilitation postoperative rehabilitation guidelines consist of 4 phases: Phase I consists of range of motion and gait training exercises. This phase focuses on protecting the repair to allow adequate healing and usually lasts 6 weeks. This is followed by a progressive, supervised strengthening program. Screen Shot 2015-10-17 at 10.50.54 Phases II and III include progressions with the speed and amplitude of movement, as well as force distribution. Early in the strengthening phase most exercises are done with both legs simultaneously in a short arc of motion either at the hip or the knee. Late in Phase III, most exercises are done in a single leg fashion with movement and force occurring at both the hip and knee simultaneously. In the final phase of rehabilitation, the focus shifts to the control of high speed movement and the development of power. This is the return to sport phase. Not all athletes will return to sport after this injury due to how significant these injuries can be. Return to sport depends on the nature of the sport, severity of initial injury, timeliness of surgical intervention and compliance with the post-operative rehabilitation program. Most studies state approximately 75% of athletes may return to their sport in some capacity. Sports requiring longer bouts of sprinting seem to be the most difficult sports to which an athlete may return.

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One Comment to "Paul O’Connell – Acute Hamstring Avulsion Injury"

  • Shane Carberry says:

    June 14, 2016 at 8:42 pm - Reply

    Hey there!

    I’ve a quick question on this that I’d love to hear your thoughts on. Although this incident wasn’t caused directly by a tissue or structural issue (I’m aware it was hip flexion with knee extension and hamstring contraction that caused the issue), is there anything that could have been done in terms of training to possibly reduce the risk of this injury occurring?

    Essentially my question is – is there any muscular or structural issues that may have needed to be addressed to reduce the risk of the avulsion of the tendon?

    Looking forward to your response!

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