Proximal Hamstring Tendinopathy

Table of content

1 Search strategy
2 Description
3 Clinically Relevant Anatomy
4 Epidemiology / Etiology
5 Characteristics / Symptoms
6 Differential Diagnosis
7 Diagnostic Procedures
8 Prevention
9 Medical Management
10 Physical Therapy Management
11 References

1 Search strategy

Databases:
PubMed
Google (Scholar)
Medical Library VUB (Jette)

Keywords:
hamstring tendinopathy
hamstring tendinitis
tendinopathy rehabilitation
high hamstring
proximal hamstring

2 Description

Hamstring origin tendinopathy, also called proximal hamstring tendinopathy or high hamstring tendinopathy, are a group of pathologies of the proximal hamstring tendon. They contain tendon degeneration, partial tearing and peritendinous inflammatory reaction. Maurice H. Zissen, et al [5]

3 Clinically Relevant Anatomy

The muscles of the hamstrings have a higher proportion of type 2 muscle fibers than the other muscles of the lower extremity. This suggests that these muscles can generate high intrinsic tension force. While running, the time increases that the hamstrings are under maximal stretch.
The hamstrings and their tendon attachments have to endure heavy charges or high tensions because of these two forces, namely during eccentric contractions. Michael Fredericson, et al [4]
For extra information about pathology mechanisms see [LINK] Tendinopathy

4 Epidemiology / Etiology

Hamstring origin tendinopathy may arise after an acute tear at the origin that is not adequately treated. Still in most cases it’s an uncommon overuse injury that is often seen in runners (more in middle- or long-distance runners than sprinters). It typically occurs with repetitive jumping, kicking and running activities.

The following factors can also higher the risk of hamstring origin tendinopathy:
Stiffness of the hip
Tightness/Weakness of the hamstrings and quadriceps
Insufficient warming up
Too hard training
Bad pelvic/core stability, Tele Demetrious and Brett Harrop [9]

5 Characteristics / Symptoms

Hamstring origin tendinopathy is related with deep buttock pain and pain in the posterior thigh. The pain increases while repetitive activity (such as long-distance running) and in worse cases pain is also mentioned while the person is sitting or driving a car.

6 Differential Diagnosis

First of all it’s essential to determine if the pain is local or referred. If the patient says that the pain varies in location it will be referred pain. Pain in the buttock combined with pain in the lower back may refer to the lumbar spine. This may be caused by a problem with muscles, ligaments or disks.

If the pain is more local and constant it’s a pathology in the buttock itself. If the pain is located near the ischial tuberosity it may represent to hamstring origin tendinopathy or also ischiogluteal bursitis.

If the patient complains of higher pain (upper gluteal region) there might be a problem with the piriformis muscle.

Pain over the sacrum or near the sacroiliac joint refers to a pelvic stress fracture or inflammation or malalignment of the sacroiliac joint.

There are also some uncommon cases where buttock and posterior thigh pain refer to chronic compartment syndrome of the posterior thigh. Michael Fredericson, et al [4]

7 Diagnostic Procedures

An MRI is required to confirm the diagnosis and to take a look at the severity of the injury. Normally a high hamstring injury may be combined with stress reaction or bone edema in the ischial tuberosity and findings of the tendon. In case of a tendinopathy an increased signal is noticeable on T1-weighted images with no abnormalities on fat-suppressed T2-weighted images. Michael Fredericson, et al; Maurice H. Zissen, et al [4,5]

8 Prevention
A good flexibility of the hamstring and quadriceps muscles is a good prevention for this injury.
Some preventive techniques related to sport and hamstring injuries are to avoid block drills in the beginning of the season or on two following days. Fu F.H. and Stone D.A. [2]

9 Medical Management

In more severe cases, when physical therapy does not help, a corticosteroid injection into the peritendinous soft tissues is recommended. It’s important to know that this does not replace the therapy but it’s a part of the therapy.
Some patients are also referred for surgery.

10 Physical Therapy Management

When a patient is diagnosed with hamstring origin tendinopathy, it's best that he goes to a physical therapist. The earlier he starts with a physiotherapy treatment the faster he’ll return to his normal function. Normally this will take a couple of weeks but sometimes, when a patient has had hamstring origin tendinopathy for a longer period, it may take months to recover. Tele Demetrious and Brett Harrop [9]

A first thing a physical therapist has to do is trying to control the pain. This occurs with ice, electrical stimulation of the tendon and pulsed ultrasound.

In the beginning of the treatment a misalignment of the pelvis has to be corrected because this might increase the tension in the hamstring muscles. It can also cause a decreased strength of the muscles.

Soft-tissue mobilization has to be included in the rehabilitation program. It’s very beneficial to break up the adhesions and scar tissue. A friction treatment with transverse frictions is commonly used. The therapist has to pay attention not to directly compress the ischial tuberosity, it can irritate underlying edema.

At the same time the patient may start a gradually built up stretching program for the hamstrings. This is also an crucial step in the process. Both legs should be stretched to have some balance. Even the antagonist hip-flexor muscles should be stretched for an optimal function. The RoM can be increased by the use of ultrasound or shockwave therapy before stretching. Frequent stretching may avoid a reappearance of the injury.

It’s important to regain strength in the muscle. First it’s best to begin with double-leg non weight-bearing isometric exercises followed by single-leg closed-chain isometrics and isotonic open-chain exercises. A good treatment for tendinopathies is an eccentric muscle strengthening program. This can normalize the thickness and structure of the tendon. It can also prepare the hamstrings for the high-force load while running.

If the RoM of the muscle is normal and pain-free, pool running and stationary biking could be put into the rehabilitation program. Reid, D.C;  Brukner P. and Khan K;  Michael Fredericson, et al;  Angelo Cacchio, et al.;  Daniel Lorenz and Michael Reiman; Mike Walden  [1,3,4,6,7,8]

11 References

[1] Reid, D.C., 1992. Sports injury assessment and rehabilitation. USA: Churchill Livingstone Inc. Pp. 415, 417, 554-570.
Level of evidence 2A

[2] Fu F.H. and Stone D.A., 1994 Sports injuries: mechanisms, prevention, and treatment. Baltimore: Williams & Wilkins. Pp. 654.
Level of evidence 3A

[3] Brukner P. and Khan K., 2006. Clinical sports medicine. 3rd ed. North Ryde NSW: McGraw-Hill Australia Pty Ltd. Pp. 388-390, 456, 546.
Level of evidence 2A

[4] Michael Fredericson, et al. High Hamstring Tendinopathy in Runners. Meeting the Challenges of Diagnosis, Treatment, and Rehabilitation [Internet]. The Physician and Sportsmedicine 2005. Available from: http://www.agilept.com/downloads/high-hamstring-tendinopathy-in-runners.pdf -
Level of evidence 2A

[5] Maurice H. Zissen, et al. High Hamstring Tendinopathy: MRI and Ultrasound Imaging and Therapeutic Efficacy of Percutaneous Coorticosteroid Injection [Internet]. American Roentgen Ray Society 2010. Available from: http://www.ajronline.org/content/195/4/993.full.pdf+html
Level of evidence 2B

[6] Angelo Cacchio, et al. Shockwave Therapy for the Treatment of Chronic Proximal Tendinopathy in Professional Athletes [Internet]. The American Journal of Sports Medicine, Vol. 39, No. 1 2011. Available from: http://www.dolorclast.com.br/humano/downloads/tratamento_pela_terapia_por_ondas_de_choque_no_tendao_proximal_do_isquiatico_cronico_em_atletas_profissionais.pdf
Level of Evidence 1B

[7] Daniel Lorenz and Michael Reiman. The Role and Implementation of Eccentric Training in Athletic Rehabilitation: Tendinopathy, Hamstring Strains, and ACL Reconstruction [Internet]. Sports Physical Therapy Section 2011. Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3105370/?tool=pubmed
Level of evidence 2A

[8] Mike Walden. Hamstring Origin Tendinitis / Tendinopathy. Sportsinjuryclinic.net 2011
http://www.sportsinjuryclinic.net/cybertherapist/back/buttocks/hamstring_tendinitis.htm
Level of evidence 5

[9] Tele Demetrious and Brett Harrop. Hamstring Origin Tendonitis. PhysioAdvisor 2008. http://www.physioadvisor.com.au/9628550/hamstring-origin-tendonitis-hamstring-injury-p.htm
Level of evidence 5