Proximal Hamstring Tendinopathy ” A pain in the backside”

To the vast majority of the population, the image of a hamstring tear will be a Sprinter pulling up in a race looking like they’ve been shot. To me, a common hamstring condition is an endurance athlete, runner, cyclist or triathlete, saying to me that they’ve got “a pain right in my ar*e” and “I’m struggling to increase my speeds as I know it’s going to go”.

It’s really important to run a full diagnostic with the evidence presented and pinpoint the cause, but invariably, the description given will lead you right to the spot, basically proximal hamstring and often right at the Ischial Tuberosity (your seat bone).

To understand what’s where, there are 3 hamstring muscles of the posterior thigh: 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 (seat bones) of the pelvis, all 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.

hamstrings

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 what’s called 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 just knee flexion.

The Injury Itself!
The common origin point of the hamstring muscles at the ischial tuberosity of the pelvis is basically the site of injury when diagnosing Proximal Hamstring Tendinopathy. The injury is classified as a tendinopathy rather than a tendonitis, as it has a more degenerative nature rather than being an inflammatory condition.

Sufferers will complain of pain local to the ischial tuberosity when running, especially when accelerating and sustained faster paced running as mentioned before. 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 (Therapist will check Glute Med and Piriformis), 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, but this can be avoided with accurate diagnosis – depends entirely on the choice of the individual!

Treatment and Rehab:
Soft Tissue Treatment, Manual Therapy & Stretching:
Hands-on treatments providing soft tissue mobilisations to break up scar tissue and adhesions can be useful, as can transverse frictions to the affected tendon. Care should however be taken not to apply direct pressure to the ischial tuberosity itself. This sort of soft tissue work is complementary to a gradual introduction to regular hamstring stretching.

If upon assessment, pelvic malalignment (anterior innominate rotation in particular) is identified, manual manipulation to restore alignment of the pelvic bones is often useful in restoring proper hamstring function. The question of course must always be asked – where does the imbalance come from that caused the pelvic malalignment…?

Specific Hamstring Strengthening
It is suggested that the progression of targeted hamstring exercises should go as follows:
Double leg, non-weight-baring isometric exercises:
Bridge Holds
Single leg isometric (closed chain) and isotonic (open chain) exercises:
Single Leg Bridge Holds
Single Leg Hamstring Catch
Eccentric hamstring loading exercises:
Swiss Ball Hamsring Curls
Single Leg Swiss Ball Hamstring Curls

It goes without saying that these progressions depend on the pain free completion of each stage.

(“Finally, you might say”) Core Strength & Pelvic Posture Correction!

Hands-on treatments, stretching and progressive strengthening are all important parts of the any good rehabilitation plan for Proximal Hamstring Tendinopathy. However, in my experience, I find the following core strengthening element to be the key to a successful outcome.

In my experience of working with triathletes/athletes/runners who suffer from proximal hamstring tendinopathy, or recurrent hamstring strains, almost all were displaying poor ability to control their pelvic position throughout the performance of functional movements for their sport.

In virtually all cases, it seems that the recurring theme is that they fall into an anterior pelvic tilt/innominate rotation during exercise; this will put the hamstring in a position where they are chronically held under tension, or put a different way, the soft tissue is now technically inelastic and unable to contract and extend from a neutral (and stable) position.

Re-educating proper pelvic position throughout movement, and working to correct imbalances which predispose an athlete to poor pelvic posture should be treated with equal importance, because if not, increased precedence over elements of the rehab programme such as eccentric hamstring strengthening protocols are potentially exacerbating the problem. It’s absolutely vital to check for quad flexibility or a dominance (unwilling to release), and tight hip flexors.

It’s very simple to prescribe a raft of general exercises that will help build stability, but equally as important, you have to treat and deal with the individual in front of you so that the balance between anterior and posterior muscle groups must be achieved first so that all you are strengthening on a “stable” platform rather than over-exerting already (technically) weakened muscles.

Get in touch with us if you want to talk further and we’d also like to hear about the topics that interest you that you’d like us to put on the website!

Train well and look forward to seeing you soon (preferrably uninjured!)

The STNW team.

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