Proximal Hamstring Tendinopathy
Article by Zoe Russell
What is Proximal Hamstring Tendinopathy?
Proximal hamstring tendinopathy, also known as high hamstring tendinopathy; is the term for an injury to the hamstring origin tendon at its attachment site into the ischial tuberosity of the pelvis.
Who Suffers from Proximal Hamstring Tendinopathy?
Proximal hamstring tendinopathy is most common in middle to long distance runners and those who participate in repetitive jumping, kicking and running sports such as soccer (football) and AFL.
What Does Proximal Hamstring Tendinopathy Feel Like?
Proximal hamstring tendinopathy often presents with the gradual onset of pain and is less likely with acute trauma.
Sufferers’ often report:
Pain is always related to loading the hamstring muscles and increases with repetitive action activities such as running and football codes. In some cases, pain can be elicited with the compressive force on the hamstring insertion from sitting.
What Causes Proximal Hamstring Tendinopathy?
The role of the hamstring tendon is to transfer the force of the hamstring muscle group to the pelvis. The hamstrings are prone to tendinopathy as they contribute to the decelerating of the straightening knee during activities such as sprinting and hill climbing (Petersen et al, 2005).
When an exercise load is applied to the proximal portion of the hamstring tendon, the tendon is responsible for transferring this load to the pelvis. The normal tendon strengthening process occurs when the tendon has to undertake this action repetitively, the tendon adapts to withstand the load. These normal tendon changes are designed to keep your body continuing to participate in your chosen activity at the performance level required for as long as possible. Normally the tendon is capable of intrinsic repair, meaning that the consequences of loading are minimal and recover in preparation for the next bout of exercise (usually 24 hours). However, if an excessive load is continually applied to the tendon, these changes occurring in the tendon can exceed the rate of repair. This can result in tendon pain and dysfunction. In some cases, the ability to repair is impaired by a multitude of factors that can result in the repair to not occur and to start to reduce the tendon’s ability to adapt, in some cases this can even result in failed healing. All of this leads to the formation of tendinopathy (Kannus 1997, Sharma and Maffulli 2005, Warden 2007).
Proximal Hamstring Tendinopathy Risk Factors
There are a number of factors that can contribute to the development of proximal hamstring tendinopathy. Your physiotherapist is the best person to discuss these with as they are highly trained to identify all the contributing factors in relation to your tendinopathy.
In some cases, proximal hamstring tendinopathy may occur following an acute hamstring tear. However, in most cases tendinopathy is an overuse injury. There are a number of intrinsic (within the athlete) and extrinsic (external to the athlete) factors which may increase the likelihood of developing injury.
Intrinsic Risk Factors:
Your physiotherapist will address any of these factors that may be influential in the development of your proximal hamstring tendinopathy. If you have any specific concerns that you would like them to investigate, please ask your physiotherapist.
Tendinopathy is a continuum of pathological processes and your treatment plan can be aided by correct identification of the current phase of injury and the application of appropriate exercise in the rehabilitation of your injury. Inappropriate loading may delay your recovery and your return to sport.
Identification of the phase helps to identify an entry point for your rehabilitation and how much you can perform in your recovery and balancing your activity levels in your rehabilitation plan.
It is very important to have your tendinopathy professionally assessed to identify your injury phase. Identifying your tendinopathy phase is also vital
to direct your most effective treatment since certain modalities or exercises should only be applied or undertaken in specific tendon healing phases.
How is Proximal Hamstring Tendinopathy Diagnosed?
Proximal hamstring tendinopathy is one of many causes of lower buttock pain. The correct diagnosis is vital to your treatment plan and recovery!
Your physiotherapist or a sports doctor can confirm the diagnosis clinically. This is undertaken with a combination of your history of injury and pain provocation tests. It is important to understand that diagnostic imaging may not be required in your diagnosis. Imaging such as MRI is often used to exclude other conditions that can mimic pain similar to proximal hamstring tendinopathy.
In some cases, an MRI may be undertaken to ensure that your injury is proximal hamstring tendinopathy and not a complete rupture of the tendon. MRI can also be used to visualise any bone marrow oedema at the ischial tuberosity in conjunction with your injury.
How is Your Rehabilitation Progress Monitored?
Your physiotherapist is highly skilled in the management of proximal hamstring tendinopathy and your subsequent safe return to sport. Among other tests, your physiotherapist will use your pain provocation tests, strength measures, and functional activities as an effective tool to monitor your pain, function and when to progress exercises or return to sport.
They’ll also be happy to discuss your injury rehabilitation with your coach.
How Do You Treat Proximal Hamstring Tendinopathy?
Proximal hamstring tendinopathy treatment has progressed significantly in recent years. Based on this, it is now more important than ever to be assessed and treated by a physiotherapist who is up-to-date in the latest proximal hamstring tendinopathy research findings and treatment strategies.
There is increasing importance in exercise in the management of tendinopathy. Isometric exercise, or exercise that the joint angle and muscle length do not change during exercise, have proven effects at pain relief for athletes suffering from tendinopathy.
How Will Your Physiotherapist Progress Your Treatment?
Tendinopathy treatment is progressed based on your tendon’s ability to withstand your exercises load. For most athletes, the traffic light system is utilised in order to clearly define how much training is too much.
Red will indicate that you need to reduce your exercise load. Amber indicates that you can exercise at current loads. Green indictaes that you can safely increase your exercise loads.
Your physiotherapist will explain how to interpret your symptoms and plan your exercise loads based upon their assessment and your symptoms.
Managing Your Activity Load is the Priority!
Exercise load management is vital to the successful treatment of a proximal hamstring tendinopathy. Mild load increases will stimulate new tendon growth. Overload leads to tendinopathy deterioration.
Reduce the load to a level that allows the tendon to recover. In severe cases, this may mean total rest from your sport or modifying training depending on the severity of tendinopathy. Your activity load should be discussed with your physiotherapist, who will plan and modify your program accordingly, based upon your pain provocation tests, traffic light response to activity and other symptoms.
When managing load you should be guided by how the tendon responds not just immediately but also 24 hours later. Tendons are known to have a latent response to loading. This means they can take 24 hours or more to react. It is important to modify your activity to remain pain-free during and for following 24 to 48 hours.
For more specific information, please discuss your tendinopathy with your physiotherapist.
Proximal Hamstring Tendinopathy Prognosis
If you identify your hamstring tendon injury in the early stages then load management and reduction will allow the tendon time to adapt and quickly recover. The reactive stage can be relatively short. Pain may settle in 5 to 10 days but the tendon will still be sensitive to high loads and training needs to be progressed gradually to prevent relapse. It is important that it does not progress into late stage 2 or stage 3 tendinopathy. These tendinopathies require additional time and rehabilitation.
Brukner and Khan (2002) suggested that a likely return to sport is in the order of 12 weeks. However, everyone is very different!
Some practitioners suggest that the prognosis with guided treatment can be summed up by the tendinopathy phase:
Exercises to Avoid with Proximal Hamstring Tendinopathy
Avoid exercises that provoke your pain such as running up hills or stairs, bending forward with a straight knee (eg, hockey) until advised otherwise by your physiotherapist.
Massage, Foam Rollers & Stretches
Massage or foam rollering of your gluteals, quadriceps, ITB, and hamstrings, may assist in cases of hamstring tendinopathy. You can perform these in positions that do not hyperflex your hip with a straight knee. Ask your physiotherapist for specific advice.
Foam rollers can be found here: http://bit.ly/15M0fOj
Eccentric exercises were for many years the "go to" exercises for tendinopathy rehabilitation. While definitely important, premature or overloaded eccentric exercises can delay your rehabilitation. Your physiotherapist will guide you when appropriate to commence strengthening that does not aggravate your hamstring tendinopathy. They may start you with isometrics that avoid tendon compression and progress from there towards a basic and then advance eccentric exercise program.
Adjacent Joints & Lower Limb Biomechanics
Researchers have identified several lower limb biomechanical issues may predispose you to hamstring tendinopathy. Your physiotherapist will assess things such as your ankle dorsiflexion, gluteal control, hip/knee bend ratio and running and landing technique. They’ll advise you if you require some treatment to address any deficiencies.
Novel therapies such as the injection of sclerosing agents, platelet-derived growth factor (PDGF), and autologous blood into diseased tendons have shown promising results, but more clinical trials are needed. Your physiotherapist is happy to discuss these options with you when they consider them an appropriate treatment option.
Remember, all tendinopathies are different. Please seek the advice of your physiotherapist to determine the best rehabilitation appropriate to your tendinopathy.
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