Proximal Hamstring Tendinopathy

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hamstring tendinopathy
hamstring tendinitis
tendinopathy rehabilitation
high hamstring
proximal hamstring
Hamstring origin tendinopathy
Hamstring tendinopathy treatment
Hamstring tendinopathy
Proximal hamstring tendinopathy

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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 , level of evidence 2B, grades of recommendation B ]

 
Clinically Relevant Anatomy

One of the most important muscle groups in running is the hamstring. They are active at multiple points in the gait cycle, namely the knee flexion and the hip extension. The distal attachment is located on the top of your tibia, just behind the knee. The origin is divided in three branches, one starting from the femur and the two remaining ones starting from the ischial tuberosity. The junction between the tendons of the hamstrings and the ischial tuberosity is the area affected by high hamstring tendinopathy. The tendon’s thickness, fibrousness and poor blood supply is the cause of a difficult healing. [10, level of eveidence 3A-4, grades of recommendation B-C]
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 Tendinopathy by Evelyne Bahire)

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 hamstrings are prone to this type of injury as they contribute to the decelerating of the extension of the knee during activities such as sprinting and hill climbing. (Petersen J. et al, 2005)
The following factors can also higher the risk of hamstring origin tendinopathy:
Intrinsic factors:
- Malalignments
- Leg length discrepancy
- Imbalance
- Decreased flexibility
A study of stretching found that there are more hamstring problems with persons who didn’t stretch before they sport. [16]
- Joint laxity
- Female gender
- Age
When you get older, there is a reduction in muscle fiber size and number. This leads to a loss of mass and strength. [16]
- Overweight
- Proprioceptive weakness (Kristine E. White, 2011)
- Ischial tuberosity tenderness
- Core weakness
- Pelvic dysfunction (Frederickson M. et al, 2005)
- Previous injury
- The strength is reduced by previous hamstrings, knee or groin injuries. [16]
- Neuromyofascial
- There is an increased neural tension and posterior thigh pain. There can be myofascial trigger points; this is associated with a decrease of flexibility. [16]
- Stiffness of the hip
- Tightness/Weakness of the hamstrings and quadriceps
- Bad pelvic/core stability, Tele Demetrious and Brett Harrop [9, level of evidence 5, grades of recommendation D]

Extrinsic factors:
- excessive, repetitive load on the body
- training errors,
- environmental malconditions
- poor equipment
- Insufficient warming up
A warm-up with isometric contractions increases strength and length of the muscle. [16]
- Excessive training
- Fatigue
- The muscle has less energy. There is also a lack of concentration, coordination and technique. [16]

Apparently core weakness and pelvic dysfunction seem to be closely related to the development of a hamstring tendinopathy. (Frenderickson et al. 2005)
The tendinopathy usually starts with micro-damage without a remarkable trauma. Normally the tendon is capable to intrinsic repair, meaning that the consequences of this injury are little.
Sometimes, imbalance can cause further damage and failed healing. All of this leads to the formation of tendinosis. (Kannus 1997, Sharma and Maffulli 2005, Warden 2007.) Intrinsic and extrinsic factors contribute to the formation of this injury. 10, level of eveidence 3A-4, grades of recommendation B-C

Characteristics / Symptoms

Hamstring origin tendinopathy is related with deep buttock pain and pain in the posterior thigh. The pain is often felt in the lower gluteal region, radiating along the hamstings (Orava 1997, Fredericson et al. 2005). 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. Usually there’s no acute trauma when the pain starts to appear, it gradually gets worse [13]. Continued exercises and stretching can cause even more pain [14, level of evidence 4, grades of recommendation C].
Pain down the back of your tigh can be caused by irritation of the sciatic nerve. This nerve passes very close to the ischial tuberosity. [10, level of evidence 3A-4, grades of recommendation B-C]
Due to its degenerative nature, this injury is classified as a tendinopathy rather than a tendonitis, an inflammatory pathology. [15, level of evidence 3A-5, grades of recommendation B-D]

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. Due to the resemblance of some symptoms of this injury with other hip injuries, it’s important to get a proper diagnosis; this will likely entail a physical examination and an MRI. Michael Fredericson, et al [4, level of evidence 2A, grades of recommendation B]

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]

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]

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.

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]

 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