13 Top Tips that will help your proximal hamstring tendinopathy
Proximal hamstring tendinopathy injuries are common among distance runners, and track and field athletes. This injury can also be common in sports that involve a lot of agility such as court or team sports. However, it is not just the athletic population that can experience proximal hamstring tendinopathy. People who sit a lot, and peri-menopausal women can develop this injury. People who suffer insulin resistance have a greater likelihood of developing this injury (1).
How do you know if you have proximal hamstring tendinopathy?
The hallmark of this condition is deep localised pain in the region of the sitting bone (ischial tuberosity) at the site of the hamstring tendon insertions (see the below diagrams for bony and tendon anatomy). The pain is characteristically aggravated by prolonged sitting, or activities such as running or squatting.
What tissue changes that occur with proximal hamstring tendinopathy?
At a tissue level hamstring tendinopathy tissue will show a greater number of cells, disorganisation of the collagen fibres (building blocks of tendons), a build-up of cell ground substance, and at times nerve and blood vessel ingrowth.
My clinical insights
At any given time I am often treating half a dozen runners with a proximal hamstring injury. Like any tendon injury, progress can often be slow, and frustration levels of the injured runner can often be high. To help ensure that a runner who is experiencing pain with their proximal hamstring gets out of pain and back to their best running in the most streamlined manner possible, here are my top ten insights garnered through ten years of clinical experience.
1. Get clear on the diagnosis.
Diagnosis determines prognosis. Your therapist or health professional needs to accurately diagnose your pain. Potential diagnoses in this region of pain can include: pain at the site of tendon insertion onto the sitting bone itself (enthesopathy), bone marrow oedema (fluid under the sub-chondral layer of bone), or a degree of ischio-gluteal bursitis. Pain in this area can also be referred from lower back conditions (such as vertebrae joint changes, discogenic conditions, or nerve root irritation or entrapment). The sciatic nerve can also generate pain at this region. In younger people with this condition a therapist needs to consider apophysitis, or an unfused ischial growth plate. In rare instances the posterior pubic ramus or ischial ramus may develop a stress reaction or fracture. Without a clear diagnosis being made treatment can potentially be misdirected, resulting in greater frustration experienced by the sufferer, and sadly often escalating treatment costs as the individual chases a definitive diagnosis.
2. Get quality imaging if chronic presentation
In chronic cases I like my clients to have an MRI. This allows for exact identification of structures that may be causal of the pain, and also quantification of the degree of tissue changes. This in turn allows for an accurate prognosis for the runner. When a injured runner has a time-frame to aim for their anxiety levels, and to a degree their frustration levels typically decrease. Having a definitive diagnosis also allows for a realistic and positive expectancy to be developed by the injured runner.
3. Monitor pain levels with activity and after activity
Some pain is acceptable during and after exercise, but pain should settle within a few hours, and should not worsen over the course of the prescribed rehabilitation process. It is not uncommon for runners to be able to continue running at an easy state within pain guidelines (click HERE for a visual pain guide>> )
4. De-load the irritated tendon
For runners this can involve reducing the number of runs, removing speed work, eliminating hills from your program, or lessening the weekly volume. For track athletes this can involve the avoidance of starts, hurdles, and speed work. If you are a triathlete I suggesting continuing to ride: avoiding hills, and big gear efforts, and also getting off the time trial bike until symptoms begin to settle.
5. Don’t stretch the hamstrings
This can create a compressive force on the tendon, in effect pushing the already sensitised tendon onto the bone, delaying recovery, and increasing symptoms.
6. Sit on a cushion
This helps reduce compressive forces at the level of the tendon insertion onto the bone. Many runners suffering more progressed hamstring injuries experience pain with sitting.
7. Use anti-inflammatories
The use of NSAIDs to help settle the pain in reactive stage. Previous concerns about NSAIDs being deleterious to tendon healing less substantiated now. NSAIDs used in the early ‘reactive’ stage of tendon pain may in fact influence tenocyte (tendon cell) stimulation (1).
8. Commence isometric loading
Commence loading of the tendon-via your physiotherapists prescription. The exercise given to you will be dependent on your load tolerance-i.e. what you can, and cannot do within appropriate pain tolerance levels. Holds of 30-60 seconds repeated 3-4 times and up to 4 times daily may be effective in reducing pain. For an idea on isometric exercise positions click HERE>>
Note: Be consistent with the completion of these exercises. As with most things in life, consistency yields great results. When it comes to corrective exercise a consistent approach, rather than a ‘perfect’ daily approach, is in my opinion superior.
9. Add isotonic exercises
As pain begins to settle isotonic (concentric and eccentric contractions) exercises can be added, whereby the focus is on performing them slowly. Exercises can include Nordic curls, prone leg curls, and prone hip extension. These can be completed every second day.
10. Build strength and capacity in your hip muscles
These include the gluteus maximus, medius, and deep hip rotatores. The effect of improved strength with these muscles is two-fold: less dominance of the hamstrings with running and activities, and a reduced degree of hip adduction (inwards collapsing of the thigh toward the midline) and internal rotation (inwards rotation of the hip). The net effect of this is reduced adverse load at the site of the hamstring insertion onto the sitting bone (ie region of pain). For further detailed information about developing hip muscle strength here are four great exercises you can begin with, click HERE>>
11. Consider Shockwave therapy
Some evidence exists for Extracorporeal Shockwave Therapy (ESWT). It may have a pain relieving effect, however it may also ‘flare’ symptoms (1). One study used ECSWT unit over a 4 week period, followed up at 3 and 12 months in a cohort of 20 PHT patients aged 18–25. A superior result to traditional conservative treatment was reported (1). The mechanism of effect remains unclear. For more shock wave information click HERE>>
12. Avoid cortisone
Stay clear of cortisone injections into the tendon structures. This may provide a good short term outcome but poorer long term outcomes. Cortisone injections may be useful if injected around the irritated tendon (peritendon) if there are treatment plateaus, or if nerve symptoms are present.
13. Be wary of PRP unless....
PRP (platelet rich plasma injections) may provide some benefit for advanced and chronic cases, however if performed in the reactive (early) phase of symptoms, the symptoms may be exacerbated. Click HERE> .
Lastly I often say to injured and frustrated runners who feel like they have lost hope of ever returning to enjoy their much loved running, that you have two options: stop and find another activity, or persist until you get the result. For the runners who value running as a high priority they typically persist-incurring costs of treatment along the way, but a cost that they are happy to spend in the return to their sport. Communication with your therapist is crucial. Your therapist at any given point on the journey towards recovery is there to coach you through the often times very long process of recovery. Without clear and transparent communication getting a great outcome is unlikely.
If you have any questions or comments please go ahead and leave them below.
Brad Beer
POGO Physio, Author You CAN Run Pain Free!
References
1. Proximal Hamstring Assessment and Management. Sport Health (Malliaris, P. and Purdam, C) Vol 32, Issue 1 (2014).
