Proximal Hamstring Tendinopathy: A Real Pain in The Butt For Runners
Proximal Hamstring Tendinopathy isn’t what people first think of when somebody mentions hamstring injuries. When most people think of running hamstring injuries, they picture the classic image of a sprinter pulling up sharply from full speed, as if hit by a sniper shot. This sort of acute hamstring tear is indeed the most common type of injury to this important muscle group. However, a less well-known but still surprisingly common injury, especially amongst endurance athletes (rather than sprinters) is Proximal Hamstring Tendinopathy. This chronic injury is often difficult to rehabilitate, frequently resulting in long and frustrating interruptions in run training.
In comparison to acute hamstring muscle tears, there is little research into Proximal Hamstring Tendinopathy (a.k.a. High Hamstring Tendinopathy or Insertional Hamstring Tendinopathy) in runners.
In this article, we’ll take a look at what the research does say, in combination with my own anecdotal observations having worked with a number of athletes suffering from this particular injury over recent years.
Anatomy of Proximal Hamstring Tendinopathy
The hamstring muscles of the posterior thigh are three in number: Semitendinosus (ST), Semimembranosus (SM) and Biceps Femoris (BF) with it’s long and short heads. Proximally, while the short head of BF attaches to the femur, all the other hamstring muscles share a common point of origin on the ischial tuberosity (sitting bones) of the pelvis, covered by the gluteal muscles.
Distally, ST and SM both attach to the medial tibia while BF attaches distally close to the fibular head, lateral to the knee.
Like all skeletal muscles, the individual hamstring muscles act to produce motion in all three cardinal planes. However, the linear orientation of their fibres, and lever arms at the hip and knee make them most effective in the sagittal plane.
When we’re taught anatomy at school, their muscle actions are described at isolated joints, in an open chain (non-weight baring) environment. We’re taught that the text-book function of the hamstrings are to contract concentrically to produce hip extension and knee flexion.
However, the hamstrings being a two-joint muscle group (crossing hip and knee), when we run there are other considerations to take into account, especially during stance phase. During this phase the foot is anchored to the ground by our body weight creating a closed chain environment. As the hamstrings contract with Glute Max to create hip extension, propelling us forwards they also create an extension moment at the knee… rather than knee flexion as we learn at school! More about this “counterintuitive muscle function” in a future post.
About The Injury
It’s the common origin point of the hamstring muscles at the ischial tuberosity of the pelvis which is the site of injury in Proximal Hamstring Tendinopathy. The injury is classified as a tendinopathy rather than a tendonitis, due to it’s degenerative nature rather than being an inflammatory pathology.
Sufferers will complain of pain local to the ischial tuberosity when running, especially when accelerating and sustained faster paced running. The pain will most likely be an intense ache in nature, rather than sharp or stabbing. Due to the anatomical proximity to the common hamstring origin, the sciatic nerve can sometimes be affected, which can cause referred pain into the posterior thigh. Once aggravated, sitting on solid surfaces can also be uncomfortable, as can direct palpation and pressing onto the ischial tuberosity manually.
Differential diagnoses for similar symptoms can include piriformis syndrome, pelvic stress fractures and low back injuries. Thus, a proper assessment from a musculoskeletal physiotherapist or similar sports injury professional is important. Often an MRI scan will be used to support diagnosis once and for all.
Testing For Proximal Hamstring Tendinopathy
In January of 2012 Cacchio et al., published a paper looking at the reliability and validity of three pain provocation tests used for the diagnosis of chronic proximal hamstring tendinopathy. They concluded that, taking into account the need for further assessment of the three tests used in the study (listed and described below), the chosen tests represent a valid, reliable means of testing for Proximal Hamstring Tendinopathy. The three tests they used in the study are as follows:
The subject actively stretches the hamstring muscles in the standing position with the hip flexed at about 90°. The knee on the testing side is fully extended and the foot is up on a support
Bent Knee Stretch Test
The BK stretch test for the proximal hamstring tightness is performed with the patient supine. The hip and knee of the symptomatic leg are maximally flexed, and the examiner slowly straightens the knee.
Modified Bent Knee Stretch Test
The patient lies in the supine position with the legs fully extended; the examiner grasps the symptomatic leg behind the heel with one hand and at the knee with the other hand, maximally flexes the hip and knee, and then rapidly straightens the knee.
As mentioned earlier, MRI and Ultrasound Imaging provides a great diagnostic resource. MRI in particular can identify tendon thickening, tearing, inflammation, and swelling in the bone at the ischial tuberosity.
Treatment & Rehabilitation Guidelines
Compared to other more common running injuries, comprehensive literature on Proximal Hamstring Tendinopathy is fairly limited. However, in 2005 Frederickson et al., at Stanford University published an insightful paper reviewing treatment and rehabilitation guidelines for high hamstring tendinopathy in runners.
Following thorough assessment and diagnosis confirmed by MRI, Frederickson’s group evaluated injured runners for core strength, hamstring flexibility and pelvic stability. The following treatment options are recommended in their paper:
Each athlete’s injury is of course different, but the guidelines above hopefully provide food for thought and some direction in the treatment and rehabilitation of such cases.
There are other treatment options available, in addition to the conservative options mentioned above. It’s not the remit of this article however to discuss options such as corticosteroid injections, shockwave therapy and surgical interventions.
Running After Proximal Hamstring Tendinopathy
As with all soft tissue injuries, it is important to take a very gradual approach to the return to running and eventually structured training. One of the biggest errors made by athletes is giving up on their rehab exercises as running is re-introduced to the programme. Hamstring problems have a nasty habit to becoming recurrent. It’s always my advice that once an athlete has suffered this sort of injury once, and successfully recovered, their rehab exercises become their maintenance exercises.
Here’s a useful programme to use to ensure a conservative reintroduction to running.
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