Proximal Hamstring Tendinopathy
What is it?
A proximal hamstring tendinopathy is a pathology of the high hamstring tendon where it attaches to the ischial tuberosity (sit bone of the buttock). Typically, we see this condition in runners who have suddenly increased their training volume/intensity, or started hill running. Those with a developed hamstring tendinopathy will complain of a deep, annoying buttock pain during activities such as hill walking, running and/or prolonged sitting/driving.
What is the cause?
There are many factors that can cause a hamstring tendinopathy, some that we have control over (extrinsic) and others that we do not (instrinsic).
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Intrinsic
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Increasing age (middle aged + )
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auto-immune disorder (such as diabetes Type 1 and 2)
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Extrinsic
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obesity
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Training errors and unaccustomed loads: such as a sudden introduction of hill running, deeper lunges at the gym, or a sudden increase in running distance
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Decreased gluteus maximus strength and bulk. The gluteal muscles act like a cushion under the hamstring tendon to protect it from compressive loads. If your gluteal muscles are small and weak then there is not much protecting the tendon.
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Tendinopathies can be thought to be on a continuum that moves through different phases. Initially, the tendons start to change shape and become thicker, due to chemical and structural changes in the tendon.
The tendon thickens in order to reduce the stress so it can cope with more loading. While the tendon continues to thicken the tendon fibres become disorganised, leaving the tendon with reduced capacity to cope with the force from the muscle contraction.
Over time due to long term overloading and poor general health, the tendon can move into the degenerative phase, where the death of tendon cells occurs and further disorganisation of the collagen fibres of the tendon. Changes in this phase are irreversible and generally means the tendon is less tolerant to load.
However, all is not lost, as there are likely portions of the tendon that aren’t in the degenerative phase whose capacity to tolerate load can be improved.
Signs & Symptoms
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Deep buttock pain with prolonged sitting, driving, running, that may radiate down the back of the thigh
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Morning stiffness felt deep in the buttock and extending down to the back of the thigh
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Pain and stiffness with initiation of activity, but as the tendon warms up, the pain will settle. After activity there is often more pain which can be delayed for up to 48 hours
What can we do about it?
Physiotherapy treatment for proximal hamstring tendinopathy varies depending on the severity and the stage the tendinopathy is in. Our physiotherapists at Sports and Spine Physiotherapy will be able to assess and diagnose which stage the tendinopathy is in and in the acute stages, provide some manual therapy as soft tissue massage in the adductor muscles can help reduce pain and improve your confidence and mobility.
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The evidence shows physiotherapy is extremely effective at managing adductor tendinopathy. Our physiotherapists will advise you on load management and provide you with a progressive strengthening program targeting the inner thigh muscles. Strength exercises help promote new tendon fibre growth and therefore help the healing of the tendon, as well as increasing the load tolerance of the tendon.
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Our therapists at Sports and Spine can help prescribe the best exercises for you, depending on your symptoms and what stage your tendinopathy is in and your current fitness levels. Exercises will start basic and slowly increase in difficulty as pain and function improve. This translates into less pain day today, greater ease of performing day to day activities and your preferred type of exercise. Your exercises will progress to sports specific exercises to ensure your tendons are exposed to similar loads to that of your sport so that their tolerance improves. Your physiotherapist can provide education and advice on how to relatively rest your tendon and avoid aggravation to allow healing in the early stages.