Proximal Hamstring Tendinopathy

Proximal hamstring tendinopathy, also called hamstring origin tendinopathy or high hamstring tendinopathy, is an increasingly common and painful overuse injury affecting the origin of the hamstring muscle group where the tendons attach at the lower pelvis. Several studies have identified different sites including the common hamstring tendon, biceps femoris, semimembranosus, and semitendinosus.

It involves damage, microtears, tendinitis, and tendinosis of the proximal hamstring tendons as they anchor onto the ischial tuberosity or sit bone (proximal hamstring origin). This leads to deep, aching pain high up in the buttock crease near where the hamstring muscles originate. The pain often radiates down the back of the thigh along the hamstring muscle bellies, which become abnormally tight and knotted from compensating for the injured tendon.

Forceful, repetitive contraction of the hamstrings through activities requiring powerful hip flexion, knee extension, and pelvic tilt can overload the proximal hamstring tendons over time. This explains why proximal hamstring tendinopathy is common in athletes performing sprinting and kicking motions.

Persistent pain, stiffness, and weakness in the proximal hamstring region warrant medical evaluation to distinguish this condition from lumbar radiculopathy or other hamstring injuries. Early diagnosis and targeted treatment provides the best prognosis for optimal recovery and minimises the risk of recurrence.

What is Proximal Hamstring Tendinopathy? (Painful Condition in the Hamstring Muscles)

• Definition – Injury and damage to the proximal hamstring tendons attaching the hamstrings to the sit bone (ischial tuberosity).
• Location – Higher up, close to the origin of the hamstring muscles in the bottom pelvis.
• Main symptom – Deep ache in the buttock crease radiating down the back of the thigh.
• Causes – Overuse from repetitive hip flexion, running, and waterskiing (insertional tendinopathy).
• Risk factors – Older age, kicking/sprinting sports athletes, dancers.
• Diagnosis – Based on symptoms, physical exam findings, MRI.
• Treatment – Rest, PT, injections, shockwave, surgery.
• Recovery – Usually several months with conservative treatment.

Understanding the typical pain patterns and activities triggering proximal hamstring issues allows proper diagnosis.

Causes and Risk Factors of Hamstring Origin Tendinopathy

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Proximal hamstring tendinopathy often results from:

• Overuse – Repetitive heavy loading through hip flexion like sprinting. Running on cambered surfaces (higher hamstring loads).
• Poor flexibility – Tight hamstrings put extra strain on the tendon attachment. Limited hip extension mobility (stretching the hamstring beyond its limit).
• Trauma – Direct contusions to the proximal hamstring area.
• Improper training – Insufficient warm-up and overload without progressive conditioning.
• Lumbar pathology – Disc issues referring pain to the hamstring origin.
• Inflammatory conditions – Contribute to tendon degradation.

Activities requiring repetitive powerful contractions of the hamstrings are high-risk. Warming up thoroughly and maintaining flexibility helps prevent injury.

Common Symptoms of High Hamstring Tendinopathy

• Deep buttock pain – patients with proximal hamstring tendinopathy suffer pain high up in the gluteal fold where the hamstring originates. Worsens with sitting.
• Thigh and hamstring pain – Ache radiating down the back of the thigh. May feel tight, and weak.
• Pain with hip flexion – Hurts when actively bending the hip, like sprinting, or lunging.
• Stiffness and tightness – In the proximal hamstring muscle belly. Feels “knotted up”.
• Warmth, swelling, bruising – Indicates inflammation from acute injury.
• Sciatic nerve irritation – Pain radiating down the leg if inflammation is near the nerve.
• Limping, altered gait – Due to antalgic compensation reducing stress on tender hamstrings.

Seek prompt evaluation for pain at the top of the hamstrings to initiate proper treatment.

Diagnosing Proximal Hamstring Tendinopathy

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Diagnosis of hamstring injuries typically includes:

• Medical history – Onset, injury mechanism, sports and activities, prior hamstring issues.
• Physical exam – Palpate for tenderness at proximal insertion, perform flexibility and strength tests. Assess gait.
• Stretch tests – Pain in passive knee flexion with hip extended suggests proximal hamstring issue.
• Imaging – MRI visualises tendon thickening, tears, partial avulsions, and calcifications.
• Injections – Local anaesthetics injected into the tendon origin helps confirm diagnosis if MRI is unclear.

Ruling out issues like disc herniation, piriformis syndrome, and sciatica allows for a proper diagnosis.

Three Pain Provocation Tests

three pain provocation tests used for the diagnosis of chronic proximal hamstring tendinopathy.

1. Ischial tuberosity tenderness test: This test involves palpating the ischial tuberosity, which is the bony prominence in the buttock where the hamstring tendons attach. The patient will experience pain or tenderness at this point if they have a proximal hamstring tendinopathy.
2. Straight leg raise test: In this test, the patient lies flat on their back and lifts their leg straight up off the ground. Pain in the buttock or hamstring area during this movement suggests the presence of proximal hamstring tendinopathy.
3. Palpation of the hamstring tendon: This test involves manually palpating the hamstring tendon near its attachment to the ischial tuberosity. If the tendon is tender and painful to touch, it indicates the presence of tendinopathy.

Treatment Approaches & Therapy

Therapy aims to relieve pain, resolve inflammation, prevent re-injury, and stimulate healing:

Acute Phase

The following methods can help alleviate acute hamstring tendinopathy.

• Rest – Avoid activities that aggravate proximal hamstring pain.
• Ice – Reduce pain and swelling. Apply 3-4 times a day for 15 minutes.
• Compression – Elastic wrap helps minimise swelling.
• Medications – Anti-inflammatories like ibuprofen for the short-term.
• Stretching avoidance – Aggressive hamstring strain or stretching early on can re-injure.

Rehabilitation Exercises

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Tendinopathy rehabilitation exercises include:

• Gentle hamstring stretches – Adds gradual length once acute inflammation resolves.
• Eccentric exercises – emphasising the lengthening phase of the muscle contraction. For example, eccentric calf raises for Achilles Tendinopathy and eccentric squats for patellar tendinopathy.
• Isometric Exercises – Submaximal pain-free isometric hamstring contractions.
• Hamstring strength – Progress hamstring strengthening as tolerated.
• Muscle balance – Include hip and core exercises.
• Hip mobility – Improve extension and internal rotation.

Additional Therapies

• Massage – Helps break down scar tissue and facilitate healing.
• Dry needling – Breaks up trigger points.
• IMS – Stimulates and stretches hamstrings through needles.
• Shockwave therapy – Stimulates tissue regeneration. Multiple sessions are often needed. It is prevalent for professional athletes to undergo therapy to treat chronic proximal hamstring tendinopathy. .
• PRP injections – Platelet-rich plasma to jumpstart healing.
• Corticosteroid injection – Potent anti-inflammatory for pain relief. Use selectively.
• Debridement – Remove abnormal tendon tissue
• Repair – Reattach partially torn tendons
• Tendon release – For tendons with significant scar tissue

Conservative treatment is successful in most patients. Surgical treatment is reserved for refractory cases with functional deficits.

Surgery

• Debridement – Remove abnormal tendon tissue.
• Repair – Reattach partially torn tendons.
• Tendon release – For tendons with significant scar tissue.

Conservative treatment is successful in most patients. Surgery is reserved for refractory cases with functional deficits.

Prevention Strategies

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Ways to help prevent proximal hamstring tendinopathy:

• Maintaining hamstring flexibility through disciplined stretching.
• Strengthening exercises for the hamstrings, glutes, hips, and core.
• Good running and training technique.
• Adequate warm-up and gradual conditioning progression.
• Not overtraining or working through pain.
• Taping or bracing for added support during activities.
• Hamstring massage before intense activity.
• Offloading with reduced hip flexion during flares.

With diligent prevention habits, proximal hamstring tendinopathy can be avoided.

Recovery Timeline and Expectations

With comprehensive rehabilitation, proximal hamstring tendinopathy recovery takes:

• Mild cases – 4 to 6 weeks with conservative measures and minimal pain.
• Moderate cases – 3 to 6 months for more significant tendon pathology and reduction in pain.
• Post-surgical cases – 6+ months for full tendon healing.

Re-injury risk is higher if returning too quickly. Follow your physiotherapist’s staged progression protocol. Recovery is very individualised.

Long-Term Outlook

The prognosis for proximal hamstring tendinopathy is generally good with a treatment regimen focused on tissue healing, muscular balance, mobility, and strength. Recurrence risk is higher in athletes performing repetitive sprinting, kicking, and hip-hinging movements. Preventive strategies, proper rehabilitation, and avoiding overload help minimise reinjury risk. New therapies like PRP and shockwave therapy can help stubborn cases heal. Listening to your body and gradually building load tolerance will get you back to activities pain-free. Seek prompt treatment for any recurring deep buttock pain, which likely signals proximal hamstring tendinopathy.

FAQs

How do you treat proximal hamstring tendinopathy?

Treatment of Proximal hamstring tendinopathy is done through rest, ice, medication, physical therapy exercises, shockwave therapy, PRP injections, and surgery for severe cases unresponsive to conservative measures.

How long does proximal hamstring tendinopathy last?

With proper treatment, mild cases resolve in 4-6 weeks. More severe tendon pathology can take 3-6 months to fully recover. Post-surgical cases take over 6 months.

How long does it take for hamstring tendinopathy to heal?

Hamstring tendinopathy can take several months to heal, depending on severity. Mild cases may resolve in 4-6 weeks with conservative treatment. Chronic cases with significant tendon damage may require 6+ months.

What aggravates proximal hamstring tendinopathy?

Activities aggravating proximal hamstring tendinopathy include repetitive hip flexion like sprinting or lunging, sitting for long periods, and aggressive hamstring stretching. Reducing provocative tendon loading early allows for healing.

Understanding proximal hamstring tendinopathy and its treatment options is essential to facilitate proper recovery and prevent re-injury.