Proximal Hamstring Tendinopathy

What is Proximal Hamstring Tendinopathy?

Proximal Hamstring Tendinopathy (PHT) is a common injury in runners. It mostly occurs in one leg (however it can occur in both!). Pain is often felt in the buttock just below the gluteal crease.

Pain presents as morning stiffness in the buttock which warms up with daily activities. Initial running is usually uncomfortable which can then warm up as the run progresses. It can return as the duration of the run or the load required increases. Soreness/stiffness returns once the runner has finished and cooled down. Pain is often at its worse later that day with standing up and walking after sitting long periods. The soreness can often remain for a couple of days. Other activities that may aggravate hamstring tendon pain include lunges, squats, excessive stretching and sitting.

Why are runners so prone to developing proximal hamstring tendinopathy?

High running training volumes lead to overuse and can quickly overload the hamstring tendon. Particularly if a sudden increase in sprint work, or hills has been performed. This is due to the hamstring working in a more flexed hip position. As a result, a compressive load is placed on the tendon where it inserts into the pelvis.

Other common activities that can trigger PHT include Yoga and Pilates. This is due to sustained stretching that applies compressive forces on the tendons while the hip is flexed. In some patients, compression from sitting too much is the aggravating factor!

How do physiotherapists diagnose proximal hamstring tendinopathy?

• The pain patterns are considered to see if they are consistent with tendon pain behaviour as described above.
• An assessment is performed by loading/stretching the upper hamstring tendon to see if the patient’s pain is reproduced.
• Palpate the ischial tuberosity to see if it is tender (Not always a positive test!)
• Imaging can be used to help confirm diagnosis.
• Alternate diagnoses are ruled out. These may include sciatic pain, lumbar radiculopathy, referred pain from the lower back/hip and sacroiliac joint pain.

How can physiotherapy help?

• Working with your physiotherapist to help create a progressive loading program is vital in reducing pain and restoring function.
• A modification of training load may also be required to help pain levels drop. This may involve temporarily reducing (not stopping!) running load. Try substituting it with cycling, swimming, or water running until pain levels improve.
• An examination of running technique may also help to reduce compression of the hamstring tendon.

Sources

• Proximal Hamstring Tendinopathy: Clinical Aspects of Assessment and Management https://www.jospt.org/doi/10.2519/jospt.2016.5986
• Image sourced from https://www.revivesportspine.com/blog/hamstingpt1