Proximal Hamstring Tendinopathy
1. Introduction
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).
Frequently Asked Questions
- It is a condition affecting the tendons of the hamstrings where they attach to your sitting bone (ischial tuberosity) causing pain on activity.
- Very rare, less than 0.5% of the population will ever suffer from the condition.
- No.
- Whilst frustrating and uncomfortable, it can improve with the right treatment (2) and it is rare for symptoms to remain long term.
- In a small number of cases, if rehabilitation does not settle the pain, further intervention may be required.
- Proximal hamstring tendinopathy is not linked to other serious conditions.
- It is more commonly seen in runners and those involved in regular, explosive sport such as sprinting and hurdling (4).
- It may also be seen in those involved in rotational sports such as hockey and football.
- Rarely affects those who do not participate in sport (3).
- Pain in the central and lower part of the buttock.
- Difficulty sitting, bending or walking (particularly uphill) (3).
- Morning stiffness in the central or lower buttock that improves quickly with movement (4).
- Increasing pain with more demanding activities such as running or sprinting (2).
- Continue with activities that do not cause your pain.
- Take regular breaks from sitting or use a pillow for extra support (3).
- Exercises that strengthen the hamstring and buttock can be started early and progressed with support from a physiotherapist.
- This will be dependent upon several factors but symptoms generally improve well with a combination of education, activity modification and exercise in 3–6 months (5).
We recommend consulting a musculoskeletal physiotherapist to ensure exercises are best suited to your recovery. If you are carrying out an exercise regime without consulting a healthcare professional, you do so at your own risk.
2. Signs and Symptoms
- Deep, central or lower pain in the buttock that often worsens during or after activity.
- Pain is often well localised to the central buttock.
- Typical activities that increase symptoms including bending forward, sitting, running and lunging (2).
- Pain often feels more noticeable after periods of rest and can improve with gentle movement (or “warm ups”).
3. Causes
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).
4. Risk Factors
This is not an exhaustive list. These factors could increase the likelihood of someone developing proximal hamstring tendinopathy. It does not mean everyone with these factors will develop symptoms. Risk factors can be divided into extrinsic (external) or intrinsic (internal) and include:
- Training error – sudden changes in training habits, such as increasing running distances too quickly or adding too much weight in the gym.
- Ergonomics – for example, long periods of sitting without adequate breaks, or poor choice of chair.
- Age – the risk of tendon pain increases as we get older due to age-related changes.
- Bodyweight – being overweight or being inactive can increase demand on your tendons.
- Medical conditions – such as diabetes, high cholesterol or smoking can make tendons more vulnerable to load.
5. Prevalence
- 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).
6. Assessment & Diagnosis
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.
7. Self-Management
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).
8. Rehabilitation
Condition specific strengthening exercises have the highest levels of evidence for the treatment of tendon pain (13). Recovery can take some time as the speed of tendon regeneration is much slower than other structures in the body and exercise may need to be changed or progressed over time.
Below are three rehabilitation programmes targeted at addressing proximal hamstring tendinopathy. In some instances, a one-to-one assessment is appropriate to individually tailor targeted rehabilitation. However, these programmes provide an excellent starting point as well as clearly highlighting exercise progression.
9. Proximal Hamstring Tendinopathy
Rehabilitation Plans
Our team of expert musculoskeletal physiotherapist have created rehabilitation plans to enable people to manage their condition. If you have any questions or concerns about a condition, we recommend you book an consultation with one of our clinicians.
What Is the Pain Scale?
The pain scale or what some physios would call the Visual Analogue Scale (VAS), is a scale that is used to try and understand the level of pain that someone is in. The scale is intended as something that you would rate yourself on a scale of 0-10 with 0 = no pain, 10 = worst pain imaginable. You can learn more about what is pain and the pain scale here.
This initial programme focuses on early, appropriate loading of the affected tendon and maintenance of lower limb strength and stability. Some of these simple strengthening exercises can be performed little and often during the day to help relieve pain and begin to strengthen your tendon. Isometric exercises (where the muscles contract against a fixed resistance without a change in the position of your leg) are an effective way to load the tendon and reduce pain in the early stages of this condition. This should not exceed any more than 5/10 on your perceived pain scale.
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Once your pain has settled to more manageable levels, you can progress to more challenging exercises that strengthen your hamstring muscles in different ranges of movement. The aim of this intermediate stage of the rehabilitation programme is to restore hamstring muscle strength and capacity in a functional range of movement. Pain during these exercises is safe and acceptable If your pain is above 5 during these exercises, you may need to reduce the amount of resistance you are using or decrease the number of repetitions you perform until the pain settles again. This should not exceed any more than 5/10 on your perceived pain scale.
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The goal of the advanced rehabilitation plan is to continue to build further hamstring strength but in positions that place greater functional strain on the hamstring. The exercises you complete here are similar to the intermediate programme, but aim to challenge your hamstring muscles through a larger range of movement, with more repetitions or increased amounts of resistance. Single leg exercises are important to address any differences in strength between your painful and non-painful side. Exercises that encourage your muscles to work for faster, shorter spells of exercise (sometimes known as plyometrics) can help prepare you for a return to sport or running. This should not exceed any more than 5/10 on your perceived pain scale.
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- 910
10. Return to Sport / Normal life
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.
11. Other Treatment Options
- 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.
12. Links for Further Reading
References
- Fredericson, M., Moore, W., Guillet, M. and Beaulieu, C. (2005). High hamstring tendinopathy in runners: meeting the challenges of diagnosis, treatment, and rehabilitation. The Physician and sportsmedicine, 33, 32-43.
- Goom, T.S., Malliaras, P., Reiman, M.P. and Purdam, C.R. (2016). Proximal hamstring tendinopathy: clinical aspects of assessment and management. journal of orthopaedic & sports physical therapy, 46, 483-493.
- De Smet, A.A., Blankenbaker, D.G., Alsheik, N.H. and Lindstrom, M.J. (2012). MRI appearance of the proximal hamstring tendons in patients with and without symptomatic proximal hamstring tendinopathy. American Journal of Roentgenology, 198, 418-422.
- Lempainen, L., Sarimo, J., Mattila, K., Vaittinen, S. and Orava, S. (2009). Proximal hamstring tendinopathy: results of surgical management and histopathologic findings. The American journal of sports medicine, 37, 727-734.
- Guex, K. and Millet, G.P. (2013). Conceptual framework for strengthening exercises to prevent hamstring strains. Sports medicine, 43, 1207-1215.
- Feucht, M.J., Plath, J.E., Seppel, G., Hinterwimmer, S., Imhoff, A.B. and Brucker, P.U. (2015). Gross anatomical and dimensional characteristics of the proximal hamstring origin. Knee Surgery, Sports Traumatology, Arthroscopy, 23, 2576-2582.
- Puranen, J. and Orava, S. (1988). The hamstring syndrome: a new diagnosis of gluteal sciatic pain. The American journal of sports medicine, 16, 517-521.
- Hansen, M., Kongsgaard, M., Holm, L., Skovgaard, D., Magnusson, S.P., Qvortrup, K., … Frystyk, J. (2009). Effect of estrogen on tendon collagen synthesis, tendon structural characteristics, and biomechanical properties in postmenopausal women. Journal of Applied Physiology, 106, 1385-1393.
- White, K.E. (2011). High hamstring tendinopathy in 3 female long distance runners. Journal of chiropractic medicine, 10, 93-99.
- Docking, S., Samiric, T., Scase, E., Purdam, C. and Cook, J. (2013). Relationship between compressive loading and ECM changes in tendons. Muscles, ligaments and tendons journal, 3, 7.
- Drew, B.T., Smith, T.O., Littlewood, C. and Sturrock, B. (2014). Do structural changes (eg, collagen/matrix) explain the response to therapeutic exercises in tendinopathy: a systematic review. British journal of sports medicine, 48, 966-972.
- Cook, J.L. and Purdam, C. (2012). Is compressive load a factor in the development of tendinopathy?. British journal of sports medicine, 46, 163-168.
- dos Santos Franco, Y.R., Miyamoto, G.C., Franco, K.F.M., De Oliveira, R.R. and Cabral, C.M.N. (2019). Exercise therapy in the treatment of tendinopathies of the lower limbs: a protocol of a systematic review. Systematic reviews, 8, 1-6.
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Hip Osteoarthritis
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Greater Trochanteric Pain Syndrome
A condition affecting the tendons that insert into outside of the hip. A common cause of pain felt around the hip and pelvis.
Femoroacetabular Impingement
A condition that results in pain in the groin, hip and down the front of the thigh.
Femoral Nerve Radiculopathy
This is where the nerve that supplies the front of the leg is irritated and causes pain/numbess.
Benign Joint Hypermobility Syndrome
Common age related changes to the structure of the knee joint which may be associated with pain, stiffness and loss of function.
Adolescent Hip Dysplasia
A result of an abnormality of the hip joint anatomy resulting in pain in the hip with occasional instability.
Adductor-Related Groin Pain
Localised discomfort to the inner upper thigh and groin.