Proximal Hamstring Tendinopathy

Other Names

• Hamstring Tendinopathy
• Hamstring Tendinosis
• Proximal Hamstring Tendinopathy (PHT)
• Hamstring Origin Tendinopathy
• High Hamstring Tendinopathy

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Background

• This page refers to subacute and chronic Hamstring Tendinopathies (HT)
  • Most commonly, this refers to Proximal Hamstring Tendinopathy (PHT)
  • Acute Hamstring Strains and Tears are a distinct clinical entities discussed separately
• See also: Tendinopathies (Main)

History

• Needs to be updated

Epidemiology

• The epidemiology of PHT is poorly described in the literature and currently unknown

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Introduction

Diagram of the hamstring muscles. BF biceps femoris muscle, ST semitendinosus muscle, SM semimembranosus muscle, CT common tendon, CT(ft) free-tendon part of the common tendon. SN sciatic nerve, IT ischial tuberosity, FH fibular head, FT fat tissue in the space between the BF and ST/SMmuscles, (*) Popliteal vessels and nerve are interposed between the BF and ST/SM muscles

General

• Defined as a chronic, overuse condition that develops as a result of repetitive mechanical loading at the proximal hamstring tendon
• Patients reliably report insidious pain at the ischial tuberosity
  • Exacerbated with sitting, driving, and activities requiring end-range hip flexion
• Primarily a based on a detailed history and physical examination
• Most patients will respond well to nonoperative management

Etiology

• Attributed to a combination of tensile loading and compressive forces applied to the common hamstring tendon
  • Near the attachment at the ischial tuberosity
  • During movements that require the hamstrings to contract or lengthen while in hip flexion and adduction
• Exercises and activities thought to increase the tensile and compressive load at the proximal tendon insertion:
  • Squatting
  • Lunging
  • Leaning forward
  • Stairs
  • Uphill running
  • Sitting for long periods

Location

• Lempainen et al reported semimembranosus pathology in all cases
• Benazzo et al found common hamstring tendon (23%), biceps femoris (41%). semimembranosus (29%). and semitendinosus (6%)
• Midportion tendinopathy in PHT has not been specifically reported in the literature
• Proximal Hamstring Tendinopathy
  • Most common location overall for tendinopathies of the hamstring muscle
  • Considered to be an insertional tendinopathy
  • Compression can occur at insertion during hip flexion, abduction

Anatomy of the Hamstring Muscle Group

• Composed of Biceps Femoris, Semimimembranosis, Semitendinosis
• Biarticular muscle group performs hip extension, knee flexion

Histopathology

• Biopsy shows increased cellularity, ground substance accumulation, collagen disorganization, and neurovascular ingrowth

Associated Conditions

• Sciatica
  • Can co-occur with fibrosis entrapment of the Sciatic Nerve between the Ischial Tuberosity and Semimimembranosis

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Risk Factors

• General
  • See: Tendinopathy Risk Factors

Sports

• Running
• Track and field, especially sprinters and hurdlers
• Hockey
• Football

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Differential Diagnosis

Differential Diagnosis Thigh Pain

• Fractures
  • Femoral Shaft Fracture
  • Femoral Shaft Stress Fracture
  • Distal Femur Fracture
• Muscle and Tendon
  • Quadriceps Tendonitis
  • Quadriceps Contusion
  • Quadriceps Tendon Rupture
  • Hamstring Strain
  • Hamstring Tendonitis
  • Adductor Strain
  • Adductor Tendinopathy
  • Rectus Femoris Muscle Injuries
• Neurological
  • Meralgia Paresthetica
  • Obturator Neuropathy
• Other
  • Myositis Ossificans
  • Acute Compartment Syndrome
  • Osteitis Pubis

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Clinical Features

Clinical demonstration of the Puranen Orava Test

Patient with proximal hamstring tendinopathy. A, Axial T2-weighted fat-suppressed image reveals increased T2 signal within tendon origin (arrowhead), consistent with tendinopathy. B, Corresponding ultrasound image shows hypoechogenicity and heterogeneity (arrows) of hamstring tendon (t) at its origin at ischial tuberosity (it).

Proximal hamstring tendinopathy-related sciatic nerve entrapment. Between the sciatic nerve (indicated by arrow) and the tendon of the semimembranosus (SM) a fibrotic accumulation is interposed (hyper-echoic area visible within the dashed box) which makes it difficult to distinguish the anatomical limits of the structures. IT=ischial tuberosity.

History

• Pain is typically insidious, no trauma is endorsed
• Patient will report lower gluteal pain, sometimes radiating to posterior thigh
• Worse with prolonged periods of sitting, running at a fast pace, jumping
• The patient may have a history of repetitive hamstring injuries
• Pain will radiate down hamstrings

Physical Exam: Physical Exam Hip

• Palpable tenderness along the Ischial Tuberosity, worse with resisted knee flexion
• Active or passive stretching can make symptoms worse

Special Tests

• Puranen Orava Test: Hip flexed to 90°, knee extended and leg placed on exam table, patient reaches for toes
• Bent Knee Stretch Test: Patient supine, hip and knee maximally flexed, knee is slowly extended
• Modified Bent Knee Stretch Test: similar to bent knee stretch test except knee is rapidly extended

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Evaluation

Radiographs

• Standard Radiographs Hip
  • Screening tool, typically normal

Ultrasound

• Advantages
  • Readily available
  • Cost-effective imaging technique
  • Allows dynamic evaluation
• Excellent screening tool prior to obtaining an MRI

MRI

• Advantages
  • Better tissue contrast
  • More sensitive than US in detecting tendinopathy, peritendinous edema

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Classification

• Not applicable

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Management

Nonoperative

• Most cases can successfully be treated nonoperatively
• Acute Phase
  • Reduction or cessation from offending activities
  • NSAIDS
  • Ice Therapy
  • Consider non-weight bearing status
• Physical Therapy
  • Emphasis on load management, biomechanics
  • Emphasis on eccentric hamstring strengthening
  • Adjunct core strength and stabilizing
  • Lumbopelvic Stabilization Exercises
• Soft Tissue Mobilization
• Trigger Point Injection or Dry Needling
• Proprioceptive Training shown to be beneficial for neuromuscular control

Procedures

• Corticosteroid Injection
  • Preferably under ultrasound guidance, alternatively with fluoroscopy
  • A single arm study among NFL players showed benefit
  • Nicholson found improvement in pain, return to sport with 38.8% reporting complete resolution following fluoroscopically guided CSI
• Platelet Rich Plasma
  • A case series review by Wetzel found benefit when compared to usual care
  • Mautner et al found >50% reduction among 180 athletes treated with PRP in a single arm study
• Extracorporeal Shockwave Therapy (ESWT)
  • Cachio et al found ESWT superior to usual care for pain reduction at a mean of 10.7 months
• Hamstring Origin Percutaneous Needle Tenotomy

Operative

• Indications
  • Failure of conservative management for an indeterminant amount of time, typically at least 6 months
• Technique
  • Semimembranosus tenotomy and exploration of the sciatic nerve

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Rehab and Return to Play

Rehabilitation

• Traditional rehabilitation protocol
  • Focuses on the progressive loading of the tendon
  • Established pain-monitoring framework
  • Goals: reduce pain, restore function, and prevent reinjury
• Heavy Slow Resistance (HSR) Training
  • Contains both concentric and eccentric phases, increasing time under tension
  • Focus: perform slow, fatiguing, progressive resistance exercise with both concentric and eccentric components
  • Has been shown to improve clinical results and patient satisfaction at 12 and 52-weeks for Achilles and patellar tendinopathy
  • Has not been studied in PHT
• Protocol proposed by Gooms et al
  • Stage 1: Isometric hamstring load
  • Stage 2: Isotonic hamstring load with minimal hip flexion
  • Stage 3: Isotonic exercises in increased hip flexion (70° - 90°)
  • Stage 4: Energy storage loading

Return to Play/Work

• Should be gradually introduced to athlete as their pain and function improve
  • Important to avoid risk of re-injury
• Progressive should be step-wise under the care of AT or PT

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Prognosis and Complications

Prognosis

• Time to full recovery is typically 1 - 3 months
  • Good results have been demonstrated with full return to pre-injury sports level
• Lempainen et al on surgical intervention
  • They found that 80 of 90 athletes reported to the same level of competition with low complication rates following surgery
  • This was after a mean of 5 months (range 2-12)

Complications

• Re-injury
• Inability to return to sport
• Chronic pain

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See Also

Internal

• Hip Pain (Main)
• Thigh Pain (Main)
• Hip Anatomy (Main)
• Physical Exam Hip

External

• https://www.sportsmedreview.com/blog/chronic-hamstring-tendinopathy-review/

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