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Proximal Hamstring Tendinopathy

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Other Names

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

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

History

  • Needs to be updated

Epidemiology

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

Pathophysiology

  • See: Tendinopathies (Main)
  • Location
    • Lempainen et al reported semimembranosus pathology in all cases[1]
    • Benazzo et al found common hamstring tendon (23%), biceps femoris (41%). semimembranosus (29%). and semitendinosus (6%)[2]
    • 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[3]

Pathoanatomy

Associated Conditions


Risk Factors


Differential Diagnosis


Clinical Features

  • 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

Evaluation

Radiographs

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[5]

Classification

  • Not applicable

Management

Prognosis

  • Time to full recovery is typically 1 - 3 months[6]
    • Good results have been demonstrated with full return to pre-injury sports level
  • Lempainen et al on surgical intervention[1]
    • 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)

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
  • Corticosteroid Injection
    • Preferably under ultrasound guidance, alternatively with fluoroscopy
    • A single arm study among NFL players showed benefit[7]
    • Nicholson found improvement in pain, return to sport with 38.8% reporting complete resolution following fluoroscopically guided CSI[8]
  • Platelet Rich Plasma
    • A case series review by Wetzel found benefit when compared to usual care[9]
    • Mautner et al found >50% reduction among 180 athletes treated with PRP in a single arm study[10]
  • Extracorporeal Shockwave Therapy (ESWT)
    • Cachio et al found ESWT superior to usual care for pain reduction at a mean of 10.7 months[11]
  • Soft Tissue Mobilization
  • Trigger Point Injection or Dry Needling
  • Proprioceptive Training shown to be beneficial for neuromuscular control[12]

Operative

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

Rehab and Return to Play

Rehabilitation

  • One proposed protocol by gooms et al[13]
    • 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

  • 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

Complications

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

See Also


References

  1. 1.0 1.1 Lempainen, Lasse, et al. "Proximal hamstring tendinopathy: results of surgical management and histopathologic findings." The American journal of sports medicine 37.4 (2009): 727-734.
  2. .Benazzo F, Marullo M, Zanon G, Indino C, Pelillo F. Surgical management of chronic proximal hamstring tendinopathy in athletes: a 2 to 11 years of follow-up. J Orthop Traumatol. 2013;14:83-89
  3. Cook JL, Purdam C. Is compressive load a factor in the development of tendinopathy? Br J Sports Med. 2012;46:163-168
  4. Lempainen L, Sarimo J, Mattila K, Vaittinen S, Orava S. Proximal hamstring tendinopathy: results of surgical management and histopathologic findings. Am J Sports Med. 2009;37:727-734
  5. Zissen MH, Wallace G, Stevens KJ, Fredericson M, Beaulieu CF. High hamstring tendinopathy: MRI and ultrasound imaging and therapeutic efficacy of percutaneous corticosteroid injection. AJR Am J Roentgenol. 2010;195(4):993–998.
  6. Lempainen, Lasse, et al. "Expert opinion: diagnosis and treatment of proximal hamstring tendinopathy." Muscles, ligaments and tendons journal 5.1 (2015): 23.
  7. Levine, William N., et al. "Intramuscular corticosteroid injection for hamstring injuries: a 13-year experience in the National Football League." The American journal of sports medicine 28.3 (2000): 297-300.
  8. Nicholson, Luke T., et al. "Fluoroscopically guided peritendinous corticosteroid injection for proximal hamstring tendinopathy: a retrospective review." Orthopaedic journal of sports medicine 2.3 (2014): 2325967114526135.
  9. Wetzel, Robert J., Ronak M. Patel, and Michael A. Terry. "Platelet-rich plasma as an effective treatment for proximal hamstring injuries." Orthopedics 36.1 (2013): e64-e70.
  10. Mautner K, Colberg RE, Malanga G, Borg-Stein JP, Harmon KG, Dharamsi AS, et al. Outcomes after ultrasound-guided platelet-rich plasma injections for chronic tendinopathy: a multicenter, retrospective review. PM R. 2013;5(3):169–175
  11. Cacchio, Angelo, et al. "Shockwave therapy for the treatment of chronic proximal hamstring tendinopathy in professional athletes." The American journal of sports medicine 39.1 (2011): 146-153.
  12. White KE. High hamstring tendinopathy in 3 female long distance runners. J Chiropr Med. 2011;10(2):93–99.
  13. Goom TS, Malliaras P, Reiman MP, Purdam CR. Proximal Hamstring Tendinopathy: Clinical Aspects of Assessment and Management. J Orthop Sports Phys Ther. 2016 Jun;46(6):483-93
Created by:
John Kiel on 11 June 2019 01:57:19
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Last edited:
5 October 2022 13:07:29
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