Susan High was no stranger to bumps, bruises and strains. She’d skied for decades, and expertly enough to have taught at Eldora Mountain Resort. She’d played competitive soccer into her forties. She had run the first Bolder Boulder in 1979 and every one since. At 71, she was playing on four tennis teams. So on May 4, when she dashed toward the net, reached for a short ball, and heard something pop as her right leg gave way, she knew, as she put it, “this wasn’t a minor injury.”

She had torn her right hamstring – the muscle on the back of the thigh – from its moorings on the lower loop of pelvis known as the ischium. The injury brought her back to a different sort of team, one she knew well: UCHealth Steadman Hawkins Clinic Denver. She’d had her left knee replaced there in 2015 and had been guided through the rehabilitation process by UCHealth Steadman Hawkins physical therapist Megan Williams. High would soon be seeing Williams again.

The surgeon this time around would be UCHealth and University of Colorado School of Medicine orthopedic surgeon Dr. James Genuario. Genuario does all sorts of surgeries on the muscles, bones and tendons people tear and break, but he’s particularly known for his skill in fixing torn hamstrings. The 75 or so hamstring repairs he does each year is more than any other surgeon in the region, he figures.

Three in one

Like its quadriceps cousin on the front of the thigh, the hamstring is technically a misnomer. It’s actually three muscles. Though that’s one fewer than the quadriceps, it one-ups its more prominent partner in that the hamstring reaches all the way from the pelvis to below the knee (the quadriceps stops above the knee).

Hamstring tears – a.k.a. “pulled hammies” – are common among athletes, particularly those in sports with sharp changes of pace and direction. The vast majority can be treated without surgery. But High had torn all three tendons from the pelvic bone. They had retracted about two inches from where they had been anchored and would never reconnect without surgical repair.

Genuario usually finds this sort of injury among two distinct cohorts, he says. Patients tend to be either young and active people who slipped while rock climbing or were thrust forward with a straight leg while skiing or waterskiing, or older people with underlying tendinopathy that weakens the tendon. Low blood flow to the hamstring tendons connecting to the ischium contributes to the problem of tendinopathy.

“As active a state as Colorado is, I see a lot of patients 55 and up with hamstring injuries,” Genuario said.

Surgery to repair an injury like High’s is technically optional, Genuario says. But not doing it risks persistent pain, weakness and disability. A further risk would be scar tissue on the damaged tendons pressing against the neighboring sciatic nerve. For someone such as High, who aimed to get back on slopes and tennis courts, surgery was essential to maintain her quality of life.

The fix

High limped around for a few days after the injury, waiting for the swelling settle down so Genuario could operate. When colleagues at the small Aurora hospital where High works as pharmacy director asked what was going on, she hiked up her right pantleg to show bruising that extended down to her lower calf. On May 16, Genuario performed the surgery.

He made a two-inch incision where leg meets rump, moved gluteal muscle out of the way, found and isolated the sciatic nerve, sutured anchors into the ischium and wove sutures into the tendon to reconnect them. Ninety minutes later, the procedure was complete. Now it was time to heal and rehabilitate.

The Bolder Boulder, 11 days later, seemed entirely out the question – a disappointment to High, one of just eight women who had run it every year since its inception. But UCHealth Steadman Hawkins physician assistant Jeremy Smith volunteered to push her through the 10-kilometer course in a wheelchair, and his prospective load quickly lightened as High’s friends from tennis and elsewhere said they’d like to help too. With all that and Bolder Boulder officials’ blessing, High was able to make it 41 straight years (check out Denver CBS4’s story here).

Megan Williams, the physical therapist, would again work with High. As Williams and colleagues do with all patients, she customized a program that combined surgery-specific recovery protocols developed and refined over many years with the specifics of High’s case. Shortly after the surgery, she met with High and explained the approach and the many milestones involved in recovery. Having worked with High through the knee-replacement rehabilitation, Williams knew her to be a motivated, dedicated rehab patient. That’s not always the case, Williams says.

“I may be biased as a PT, but I think the rehab is equally important as the surgery. If you don’t rehab properly, you’ll never regain the strength, the motion, or the desired level of function,” Williams said. “I’m always surprised when patients don’t do the rehab.”

Different program

This would be a much different sort of rehabilitation, though. A knee replacement is as strong as it’s ever going to be the moment a patient rolls out of the operating room. A hamstring repair must be treated gingerly. For six weeks, High wouldn’t be allowed to put any weight on it at all – nor could she even drive. Then, over a period of weeks, Williams and High would slowly work on muscle groups above and below the hamstring, then on the stretching and strengthening the hamstring, and finally on patient- and sport-specific training. Steadman Hawkins’ protocols are specific to the point that a baseball outfielder’s late-stage rehab will differ from that of a pitcher; same with a football quarterback and a running back.

High’s expectations are, well, high: she intends to be back on the tennis court helping her multiple teams, back on the slopes, and back at the Bolder Boulder without Jeremy Smith serving as a vastly overqualified wheelchair motor. Williams is planning accordingly.

“If I have someone who wants to get back to gardening, I’m not going to have them doing plyometric box jumps,” she said. “But if they want to get back to skiing, yeah.”

High was walking again by July; by September, light jogging could be in the cards. Patients are typically able to return to their normal activities six months after surgery, he says. High, to no surprise, has more aggressive ambitions.

“I’m thinking four to six months,” she said.

She, Williams and Genuario will gauge her progress and, presumably, come to a negotiated settlement. Regardless, the surgeon takes real pleasure in seeing patients regain what they otherwise might have lost.

“When someone gets back out there running again and doing what she loves to do, it just makes it all worthwhile,” Genuario said.