Chronic high hamstring tendinopathy is often called the runner’s curse – and for a good reason. This overuse injury is common in runners and sports, including football, rugby, hockey, and athletics. So what is proximal hamstring tendinopathy, and how do we treat it? Is a hamstring injection an option?
Where is the proximal hamstring tendon?
The proximal hamstring tendon consists of two tendons – the semimembranosus and conjoint tendons. They are like two mountains attaching to the part of the back of the sitting bone, also called the ischial tuberosity.
Generally, we think that the outer semimembranosus tendon is more likely to be injured due to the muscle’s particular characteristics and the tendon’s position. For example, we believe the semimembranosus tendon stretches more when the hip is flexed, leading to higher tension on the tendon during running and sport.
Causes of chronic high hamstring tendinopathy
Generally, when too much load is placed on the tendon, the tendon swells, causing tendinopathy. Too much load can occur with inappropriate or excessive training. Examples of improper training include too much hill running, interval training, and insufficient rest. People who perform regular Yoga can also suffer from this condition.
Diagnosis
Overall, a clinical assessment by an experienced doctor is needed to make an accurate diagnosis and rule out other causes.
Generally, people report deep pain in the buttock near the tendon’s attachment to the sitting bone. Usually, pain starts without an acute injury. Pain warms up with activity but gets worse after exercise. Hamstring stretching and sitting can make the pain worse. In particular, driving is problematic.
Usually, clinical examination reveals tenderness at the site of the hamstring origin tendon. In addition, pain occurs with resisted hamstring exercises on the bed, such as a resisted hip extension or leg hamstring bridge.
In general, imaging helps confirm proximal hamstring tendinopathy and rule out other causes of buttock pain. Overall, MRI is the investigation of choice. One study found that swelling in the ischial tuberosity bone was associated with pain of hamstring tendinopathy. In addition, MRI can pick out partial tendon tears, which some doctors treat differently. Ultrasound also demonstrates tendon swelling but is not so good for partial tears.
High hamstring tendinopathy vs. piriformis syndrome
Generally, many other causes of buttock pain can mimic hamstring tendinopathy. For example, piriformis syndrome causes pain in the buttock with occasional radiation into the leg. In these cases, the piriformis muscle is tender to touch, and pain occurs with resisted external hip rotation. Often, hamstring tendonitis signs are absent in piriformis syndrome.
Other causes of buttock pain similar to hamstring tendonitis include:
- pain from the lumbar spine or sacroiliac joint
- ischiofemoral impingement
- hip arthritis
- hip impingement
- pelvic stress fracture
- nerve pinching in the groin or pelvis
- deep gluteal syndrome
Can proximal hamstring tendinopathy cause sciatica?
The sciatic nerve can pinch from the lumbar spine to the thigh. We call this condition deep gluteal syndrome. At the level of the sitting bone, the sciatic nerve is close to the hamstring origin tendons. A recent study found that the sciatic nerve was about 1.2cm from the hamstring tendons – increasing the risk of pinching if the hamstring tendons swell. Diagnosing sciatic nerve irritation at the level of the sitting bone is challenging. Often, imaging fails to show definite nerve pinching. Sometimes, an injection between the nerve and tendon can be diagnostic and help with symptoms.
Hamstring tendinopathy treatment
Generally, treatment of hamstring tendonitis is challenging as symptoms can be difficult to resolve.
Initially, you should reduce the number and volume of running or training sessions by 50%. Generally, you should avoid provocative activities such as sprinting, hill runs, and full squat. Reducing your training and altering your exercise will help with the pain. In addition, you should aim to make tendon pain stable, i.e. pain after activity that is low-level and lasts for less than 24 hours. On the contrary, unstable pain usually lasts for days and sometimes weeks.
Other simple treatments include massage and ibuprofen for a short period (2-4 weeks). You should also avoid prolonged sitting and hamstring stretching in the early stages.
Proximal hamstring tendinopathy exercises
It is essential to strengthen the hamstring muscle. In general, we recommend three strengthening sessions per week. We suggest you start with exercises such as plank roller, hamstring bridges, and hamstring curls. Later, hip thrusters, step-ups and Nordic curls can be added. Generally, people should perform single-leg exercises as double-leg exercises have less effect on the painful side. Also, you need to work on both sides, as research suggests strength loss occurs on the pain-free side.
Examples of strength goals we use for hamstring tendonitis include single-leg prone curl with 15-30kg added weight, single-leg deadlift with 15-30kg barbell, or step up with 15-30kg barbell.
As strength improves and you are close to achieving your strength goals, we introduce exercises that add more hip flexion and speed. These exercises include walking lunges, sideways lunges, and sled pushes. Plyometric drills include jumping split squats and jumping lunges. Also, we should not forget the other muscles in the pelvis and leg, including the calf, quadriceps, and gluteal muscles.
Finally, hip flexor tightness increases running demands and should be corrected.
Running with hamstring tendinopathy
Running can commence once strength weakness has been corrected. We suggest running slowly and steadily, progressing to accelerations and side-to-side movements. Generally, we recommend running on different days to the strength sessions.
Adjuncts to exercise
Sometimes, despite a good strengthening program, people have persistent pain. In these cases, we use other treatments to help.
Collagen supplements for tendonitis
Hydrolysed collagen supplements taken 30 minutes before Achilles tendon loading exercises show a more significant improvement in tendon pain compared to exercises alone. We recommend taking collagen supplements to enhance the effect of exercise therapy.
Shockwave therapy for hamstring origin tendinopathy
Shockwave therapy directs sound waves to the area of tendinosis. We think that shockwave has two effects: it remodels the tendon and stuns the pain nerves in the tendon. A recent study found that radial shockwave therapy was effective for hamstring tendonitis. We suggest one session every seven days for 4-5 sessions.
Hamstring injection
Cortisone injection for hamstring origin tendinopathy
Cortisone injections improve pain in the short term, but long-term outcomes are unknown. Generally, we suggest injecting the tendon sheath just outside the tendon. Also, injections should be performed with ultrasound guidance to improve accuracy and avoid injecting into the tendon or nerve.
Overall, we advise caution when injecting hamstring origin tendons with a partial tear due to the risk of a complete tear.
High-volume nerve stripping injection for hamstring origin tendinopathy
In cases of pinching of the sciatic nerve by the hamstring tendons, we recommend injecting cortisone and sterile water between the nerve and the hamstring tendon. This hamstring injection aims to strip the nerve away from the tendon and reduce pinching of the nerve.
PRP injection for hamstring origin tendinopathy
PRP injections aim to inject growth factors into the tendon to regenerate or heal the tendon. Generally, for hamstring origin tendinopathy, results are mixed. In our opinion, we should reserve PRP injections for tendons with partial tears that have failed other treatments.
High hamstring tendinopathy surgery
Overall, we reserve surgery for cases that fail all other treatments. Generally, we perform two types of surgery: repair of the tendon for tears and, in cases of sciatic nerve irritation, the release of the nerve from the hamstring tendons. Both surgeries have risks, and outcomes are unpredictable.
Final word from Sportdoctorlondon about chronic high hamstring tendinopathy
Chronic high hamstring tendinopathy is common in runners and sportspeople but must be differentiated from other causes of buttock and hamstring pain. Often, many cases of buttock pain are misdiagnosed. You should see a doctor who is experienced in making a correct diagnosis.
The title is correct: it is a curse. I had this problem for 4 or 5 years. I’m not a runner, I’m a cyclist and it kept me off my mountain bike for months at a time. I worked with a rehab pilates person. One day I was doing some zone 2 training on my Peloton and the instructor mentioned that it’s quite usual for the glute to not engage. I thought, “hmm, I don’t feel my glute ever get fatigued.” And I took that information to my rehab person. Well, we began exercises to “wake up” my glutes and in a matter of a couple of weeks it was gone. I continued to do a few glute exercises before every ride and I was not only feeling 90% better, but back to my sport! As time went on, I no longer needed to wake up my glutes prior to a ride, they just activate on the bike. Now when I’m getting fatigued my glutes are tired just like my quads and I don’t have “runner’s bum” any more.
One note though: I began weight training this year with a trainer. I did have to work up to doing dead lifts and goblet squats. At first it threatened the problem but we went slow and now I can do these exercises, no problem!
Hope this helps!