Proximal Hamstring Tendinopathy

The hamstring muscles (known as semimembranosus, semitendinosus and biceps femoris) are three muscles that are located at the back of the thigh. These muscles work in conjunction with other powerful muscles to allow you to walk, run and move normally. The proximal (closer to the centre of the body) hamstring tendons connect the three hamstring muscles to the pelvis forming one large tendon, deep in the buttock ⁽⁶⁾.

When there is pain in this tendon, we call it proximal hamstring tendinopathy. Proximal hamstring tendinopathy can be a cause of buttock pain in those participating in activities such as running, sprinting and hurdling ⁽²⁾. This condition can include tendon degeneration, partial tearing and peritendinous (outside layer) inflammatory reactions. However, it is also seen in those who are not active ^(7,8).

Proximal hamstring tendinopathy, like any form of tendon pain, is caused by the relationship between the demand placed on the tendon (load) and the rate at which the tendon can adapt or regenerate (repair) ^{(9, 10)}. Tissue samples taken from people with tendon pain tend to show similar findings, which suggest the tendon has tried and failed to regenerate, unable to cope with the load placed upon it ⁽¹⁰⁾. This in turn can lead to pain and weakness with activities that place further demand on the tendon. It is important to note that rarely is there any evidence of tendon “damage” and findings on medical images do not always correlate well with pain or function ⁽¹¹⁾.

• Overall the incidence of proximal hamstring tendinopathy is low and occurs mostly in athletes.
• It accounts for approximately 3.1% of all tendinopathies in athletes ⁽⁴⁾.

Musculoskeletal physiotherapists and other appropriately qualified healthcare professionals can provide you with a diagnosis by obtaining a detailed history of your symptoms. A series of physical tests might be performed as part of your assessment to rule out other potentially involved structures and gain a greater understanding of your physical abilities to help facilitate an accurate working diagnosis ⁽¹²⁾.

Your treating clinician will want to know how your condition affects you day-to-day so that treatment can be tailored to your needs and personalised goals can be established. Intermittent reassessment will ascertain if you are making progress towards your goals and will allow appropriate adjustments to your treatment to be made. Imaging studies like magnetic resonance imaging (MRI) scans are usually not required to achieve a working diagnosis, but in unusual presentations they may be warranted.

There are several things you can do to address symptoms. Training (or load) modification is the most important first step towards reducing and managing your pain. This may require reducing the number of times you go for a run, reducing the distance or speed that you run or avoiding activities that involve repetitive forward bending. Avoiding long periods of sitting, or using a cushion, can help reduce compression of the tendon and allow pain to settle.

Once pain has settled to a more manageable level, exercise(s) to strengthen your hamstring or buttock muscles can help reduce pain, improve function and enable you to slowly return to activities that you enjoy ⁽²⁾.

For patients wanting to achieve a high level of function or return to sport, we would encourage a consultation with a physiotherapist as you will likely require further progression beyond the advanced rehabilitation stage. Before returning to sport, a rehabilitation programme should incorporate plyometric based exercises; this might include things like bounding, cutting, and sprinting exercises ^(5,7).

As part of a multi-modal treatment approach, your musculoskeletal physiotherapist may also use a variety of other pain-relieving treatments to support symptom relief and recovery. Whilst recovering, you might benefit from further assessment to ensure you are making progress and establish appropriate progression of treatment. Ongoing support and advice will allow you to self-manage and prevent future reoccurrence.

A graded return to sport can be introduced when you can manage the exercises suggested in the advanced rehabilitation programme with minimal pain during, and 24 hours after, you have completed them. For runners, starting with manageable distances that you can accomplish with minimal pain during, or 24 hours later, is suggested. This can be gradually progressed, and symptoms monitored to ensure you do not provoke your symptoms.

• Physiotherapy alone can significantly improve symptoms. However, in persistent and irritable cases alternative options and/or more invasive treatment such as those detailed below might be required.
• Non-steroidal anti-inflammatory medication prescribed by an appropriately qualified healthcare professional may have a role in settling an irritable proximal hamstring tendinopathy.
• Corticosteroid injections may have a role to play in those who have exhausted and failed conservative management. However, it is important to be transparent and acknowledge that in some research they have been found to have a negative impact on tendons.

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