Chronic Hamstring Tendinopathy

What is Chronic Hamstring Tendinopathy?

Chronic hamstring tendinopathy is a condition characterized by a deep pain in the buttocks and upper part of the back of the thigh. It is also referred to as chronic high hamstring tendinopathy or proximal hamstring tendinopathy.

The hamstring is a group of three muscles that run along the back of the thigh from the hip to the knee and are connected with tendons to the part of the pelvic bone we sit on called the ischial tuberosity. Due to continual physical activity, these tendons undergo degenerative and inflammatory changes, causing pain in this area and are susceptibility to injury.

Causes of Chronic Hamstring Tendinopathy

There are several factors that can lead to chronic hamstring tendinopathy. These include:

Intrinsic factors

• Increased age
• Reduced flexibility
• Being overweight
• History of a previous hamstring tendon injury
• Tendinitis (Inflammation of tendon)
• Pelvic dysfunction 
• Stiffness in the hip
• Autoimmune disease

Extrinsic factors

• Repetitive movements such as running, biking, or rowing
• Improper training or overtraining
• Poor warmup
• Muscle fatigue
• Environmental factors

Symptoms of Chronic Hamstring Tendinopathy

Pain is one of the most common symptoms of chronic hamstring tendinopathy and is usually felt at the back of the hip on the “sit bones,” where the hamstring begins. You may experience:

• Buttock pain
• Pain while bending
• Pain while sitting
• Pain during repetitive physical activity or acceleration
• Thigh pain
• Muscle stiffness

Diagnosis of Chronic Hamstring Tendinopathy

Your doctor will review your medical history and symptoms and perform a physical examination as needed. The area of the sit bones will be palpated for tenderness, and the hamstrings evaluated for a range of motion. Tests often performed to diagnose chronic hamstring tendinopathy include:

• Physical tests: The following tests detect pain and range of motion of the hamstrings.
  • Bent Knee Stretch Test: Your doctor will have you lie in a supine position with the knee and hip maximally bent. The lower leg is then slowly brought up, extending the knee to see if you experience pain in the hamstrings.
  • Modified Bent Knee Stretch Test: While on your back, your doctor will slowly lift the affected leg by the heel and bend the knee and hip maximally. The leg is then rapidly straightened to see if you have pain in the hamstrings.
  • Puranen-Orava Test: In a standing position your lower leg is raised and the foot supported with the hip at 90 degrees and the knee extended.  Your upper body is then bent towards the raised leg, stretching the hamstrings to see if you experience pain.
• Imaging tests:  
  • MRI scan: This study produces images that help in detecting damage, inflammation to tendons, ligaments, or other tissues using large magnetic fields and radio waves. MRIs can help identify tendon thickening or swelling and any injury (tear).
  • Ultrasound scan: This study uses sound waves of high frequency to produce images of the tendons, ligaments, and muscles.
  • CT scan: This scan uses multiple x-rays from different directions to produce detailed images of the tissues.

Treatment for Chronic Hamstring Tendinopathy

Chronic hamstring tendinopathy responds slowly to conservative treatment methods and healing usually takes about 3-6 months. Some of the most common treatment methods include:

• Rest: You will be instructed to rest and avoid activities that aggravate your condition as this helps the tendons to recover from the damage.
• Ice and heat: Applying ice for 10 to 20 minutes every 3-4 hours is recommended. This helps to reduce pain and inflammation. Heat treatment is also recommended as this helps release scar tissue.
• Exercises: Stretching and strengthening exercises can help improve the flexibility and stability of the muscles. However, these should be performed with precise form and technique under the guidance of a physical therapist. 
• Anti-inflammatory drugs: Your doctor may prescribe non-steroidal anti-inflammatory drugs to reduce inflammation. Corticosteroid injections may also be recommended.
• Extracorporeal shock-wave therapy: In this procedure, a specialized probe is attached to the skin that sends shock waves into the soft tissues. This helps to promote healing and reduce pain.
• Platelet-Rich Plasma Injections (PRP): Ultrasound-guided PRP injections may be recommended to promote healing of the damaged tendons.
• Ultrasound-Guided Needle Tenotomy: In this ultrasound procedure, a needle is inserted through the skin into the tendon and manipulated to cause tissue damage and bleeding. As a result, platelets are attracted to the area, promoting healing.

• Complete Tenotomy: This is a minimally invasive technique in which the tendon is excised and attached to the bone.
• Debridement: This is a minimally invasive technique in which damaged tendon tissue is removed so that healthy tissue may grow in its place.