Proximal Hamstring Injuries

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This article focuses on proximal hamstring tendinopathy.

Aetiology

Extrinsic factors: training errors such as increasing volume or intensity too quickly, excessive static stretches involving end-range hip flexion, compressive load from sitting

Systemic factors: Genetic factors, age, BMI, insulin resistance, loss of oestrogen at menopause, fluoroquinolone antibiotics

Clinical Features

Examination

Main article: Hamstring Examination

Treatment

See also: Tendinopathy

Load Modification

Reduce compression (excessive hip flexion) and energy storage loads until pain has settled. Aim for a pain score of 0-3 with mild activity that settles within 24 hours following moderate to high tendon load such as repeated lunging.

In severe cases all compression and energy storage loads should be ceased until the pain has reduced and stabilised.

To maintain fitness, the provocative activity can be replaced with alternative activities such as cycling in a standing position, and swimming.

The patients posture may need to be adjusted to reduce sustained compression loads. For example excessive anterior pelvic tilt may need to be modified. Also assess for hip flexion in standing, sleeping, and sitting.

If prolonged sitting is required then the patient can use a shaped cushion to allow the body weight to sit on the posterior thighs rather than the ischium.

Repeated hamstring stretches should be avoided in the early reactive phase. Also the patient should movements that are hip-flexion dominant such as repeated lifting and trunk flexion.

Progressive Loading

Rehabilitation should involve progressive loading while monitoring pain levels. The whole kinetic chain should be treated. Energy storage and release is generally the final phase of rehabilitation.

There are no randomised controlled trials for loading programmes. Goom et al have synthesised the available evidence to provide a sample programme.[1]

They recommend that pain is monitored daily at the same time with a load test. They suggest a short- or long-level bridge, arabesque. Pain scores of 0-3/10 are acceptable during and following exercise, but the symptoms should settle within 24 hours, and shouldn't progressively worsen over the programme. Their programme is four stages and takes 3 to 6 months.

See the PDF on ResearchGate.

Adjunct Treatments

Extracorporeal shock wave therapy has studied in a trial showing superior results compared to conservative management. The mechanism of action is unclear.[2] Goom suspects that it may be more effective in modulating the pain in less reactive tendinopathies rather than early-stage reactive tendinopathies.[1]

Peritendinous corticosteroid injections can be used to provide short term pain relief, however clinical experience has shown that symptoms tend to recur.[1] Corticosteroid injections are not used very often in general for certain tendinopathies due to concerns of worsening symptoms in the long run.

There is no good evidence to support the use of platelet rich plasma injections.[3]

Resources

  • Degen[4] for an open access review of chronic insertional tendinopathy, partial-thickness hamstring tears, and complete hamstring avulsions
  • Goom[1] for a comprehensive review of hamstring tendinopathy. Full text available from ResearchGate

Differential Diagnosis of Proximal and Distal Posterior Thigh Pain

Differential Diagnosis

Proximal thigh

  • Soft tissue causes
    • Hamstring sprain
    • Hamstring Tendinopathy
    • Adductor sprain
    • Semimembranous or ischiogluteal bursitis
    • Ischiofemoral impingement
  • Referred pain
  • Neurological
    • "Hamstring syndrome"
    • Nerve entrapment of posterior cutaneous or sciatic nerves
  • Fractures
    • Femoral neck or shaft stress fracture
    • Posterior pubic or ischial ramus stress fracture
    • Ischial tuberosity apophysitis/avulsion fracture
  • Posterior thigh compartment syndrome
  • Myositis ossificans of the hamstring muscle
  • Pelvic bone tumours
  • Iliac artery endofibrosis
  • Apophysitis or avulsion in adolescents

Distal thigh

  • DVT
  • Meniscal injury
  • Gastrocnemius injury
  • Popliteus injury
  • Popliteal artery entrapment syndrome
  • Popliteal cyst

References

  1. โ†‘ 1.0 1.1 1.2 1.3 Goom et al.. Proximal Hamstring Tendinopathy: Clinical Aspects of Assessment and Management. The Journal of orthopaedic and sports physical therapy 2016. 46:483-93. PMID: 27084841. DOI.
  2. โ†‘ Cacchio A, Rompe JD, Furia JP, Susi P, Santilli V, De Paulis F. Shockwave therapy for the treatment of chronic proximal hamstring tendinopathy in professional athletes. Am J Sports Med. 2011 Jan;39(1):146-53. doi: 10.1177/0363546510379324. Epub 2010 Sep 20. PMID: 20855554.
  3. โ†‘ Moraes VY, Lenza M, Tamaoki MJ, Faloppa F, Belloti JC. Platelet-rich therapies for musculoskeletal soft tissue injuries. Cochrane Database Syst Rev. 2014;4:CD010071. http://dx.doi.org/10.1002/14651858.CD010071.pub3
  4. โ†‘ Degen. Proximal Hamstring Injuries: Management of Tendinopathy and Avulsion Injuries. Current reviews in musculoskeletal medicine 2019. 12:138-146. PMID: 30806898. DOI. Full Text.