The ABC’s of PHT: A Guide to Proximal Hamstring Tendinopathy

What is proximal hamstring tendinopathy?

Proximal hamstring tendinopathy (PHT) is a common injury among distance runners and endurance athletes. It is especially prevalent in those whose jobs involve long periods of sitting. It presents as deep gluteal (butt) pain that worsens with running and accelerating. This would show up when sprinting on foot or bike, as well as ascending hills on foot or bike. Additionally, sitting on hard surfaces is often a trigger.1 If this type of pain persists greater than 3 months it is generally considered to be a tendinopathy.

The hamstring muscles include the semimembranosis, semitendinosis, and biceps femoris. All of the hamstring muscles attach to the ischial tuberosity of the pelvis, also known as the “sits” bone. This is the part of the pelvis that bears weight during sitting. This attachment is highlighted in the picture below by the red circle.

(http://www.roberthowells.com.au/wp-content/uploads/2016/04/hamstring-yoga-anatomy.png)

Another anatomical feature that may further complicate PHT is its proximity to the sciatic nerve. As seen below, the sciatic nerve runs very close the insertion of the hamstrings into the ischial tuberosity.

(http://painmuse.org/wp-content/uploads/sciatic.jpg)

PHT occurs when the tendon attached to the “sits bone” undergoes repetitive stress, such as during distance running or prolonged sitting. Over time, this leads to degeneration of the tendon, as evidenced by disorganization of collagen fibers. (These are the fibers that give tendons their strength). It also leads to increased nerve sensitivity, areas of cell death, and increased amount of white blood cells, which are part of the body’s defense system.2

What predisposes a person to proximal hamstring tendinopathy?

There are multiple factors that contribute to developing PHT such as:

  • Prolonged sitting2 (such as during work or cycling)
  • Increasing training load too quickly1
  • Athletes younger than 403
  • Aging adults3
  • Male gender3
  • Distance running1
  • A “low hamstring to quad ratio”–meaning the hamstrings are disproportionately weaker than the quads1
  • Inflexible hamstrings1
  • Inadequate warm up before exercise1
  • Previous hamstring injury1
  • Trunk instability4
  • Biomechanical abnormalities4

However, it is important to note that having one of these factors does not predestine one to developing PHT.

How can we treat proximal hamstring tendinopathy?

Fortunately, PHT is a highly treatable condition that involves a combination of multiple techniques. It is important that the specific combination of techniques is tailored to the individual. This may vary considerably based on each patient. A consultation with a physical therapist will be essential in helping to determine the specific biomechanical contributing factors to PHT. We can then tailor an appropriate combination of therapeutic techniques.

Multiple researchers have overwhelmingly concluded that amongst the greatest treatment for PHT is eccentric hamstring strengthening exercises.1,3,4,5,9 The following eccentric exercises have been shown to be most effective:

  • Hamstring curl on swiss ball1,4,5,9
  • Single leg standing windmills4
  • Prone hamstring curls with an eccentric focus (ex: 2 seconds up 5 seconds down)1,4,5,8
  • Bridge walk outs4,9
  • Eccentric hamstring control on treadmill5
  • Nordic Hamstring Curls8

There is also substantial evidence supporting the use of lumbo-pelvic (trunk) stabilization exercises. The following exercises have been shown to be effective:

  • Single leg stance exercises 4
  • Planks4,9
  • Side-planks4,9
  • Bridges4,9

There are also various modalities that have been shown to be effective for treating tendinopathies such as PHT:

 How long does it take for one to return to regular activity after dealing with PHT?

The amount of time it takes for one to resume regular activity following PHT will vary greatly depending on the individual. It can be estimated that, when effectively treated, PHT symptoms will resolve between 2-6 months.1,3,9

 Are there other options besides physical therapy?

            If conservative treatment fails to resolve PHT, there are medical options that may assist in relieving symptoms such as:

  • Corticoid injections10
  • Tenotomy surgery11

Take control of PHT! 

If these symptoms sound familiar, be sure to schedule an appointment with a physical therapist in order to determine the best plan for you!

By: Noah Bernhardt, SPT in conjunction with Dave Nissenbaum MPT, LAT, OCS and Jeff Schleusner DPT, PRO Physical Therapy

References:
  1. White KE. High hamstring tendinopathy in 3 female long distance runners. J Chiropr Med. 2011;10(2):93-99
  2. Erickson, M. (2016, February 22) “Musculotendinous Pathology” presented in Musculoskeletal Disorders II. Carroll University, Waukesha, WI. Lecture Carroll university Dr. Mark Erickson, February 2016.
  3. Lempainen L, Johansson K, Banke IJ, et al. Expert opinion: diagnosis and treatment of proximal hamstring tendinopathy. Muscles, Ligaments and Tendons Journal. 2015;5(1):23-28.
  4. Jayaseelan D, Moats N, Ricardo C. Rehabilitation of Proximal Hamstring Tendinopathy Utilizing Eccentric Training, Lumbopelvic Stabilization, and Trigger Point Dry Needling: 2 Case Reports. Journal of Orthopaedic & Sports Physical Therapy. 2014;44(3):198-205. doi:10.2519/jospt.2014.4905.
  5. Cushman D, Rho M. Conservative Treatment of Subacute Proximal Hamstring Tendinopathy Using Eccentric Exercises Performed With a Treadmill: A Case Report. Journal of Orthopaedic & Sports Physical Therapy. 2015;45(7):557-562. doi:10.2519/jospt.2015.5762.
  6. Tumilty S, Munn J, McDonough S, Hurley D, Basford J, Baxter G. Low Level Laser Treatment of Tendinopathy: A Systematic Review with Meta-analysis. Photomedicine and Laser Surgery. 2010;28(1):3-16. doi:10.1089/pho.2008.2470..
  7. Mostafavifar M, Wertz J, Borchers J. A Systematic Review of the Effectiveness of Kinesio Taping for Musculoskeletal Injury. The Physician and Sportsmedicine. 2012;40(4):33-40. doi:10.3810/psm.2012.11.1986
  8. McCormack J. The management of bilateral high hamstring tendinopathy with ASTYM®treatment and eccentric exercise: a case report. Journal of Manual & Manipulative Therapy. 2012;20(3):142-146. doi:10.1179/2042618612y.0000000003.
  9. Fredericson, M, Moore, W., Guillet, M., and Beauleieu. High Hamstring Tendinopathy in Runners Meeting the Challenges of Diagnosis, Treatment, and Rehabilitation. The Physician and Sportsmedicine. 2005;33(5):0. doi:10.3810/psm.2005.05.8
  10. Zissen M, Wallace G, Stevens K, Fredericson M, Beaulieu C. High Hamstring Tendinopathy: MRI and Ultrasound Imaging and Therapeutic Efficacy of Percutaneous Corticosteroid Injection. American Journal of Roentgenology. 2010;195(4):993-998. doi:10.2214/ajr.09.3674.
  11. Lempainen L, Sarimo J, Mattila K, Vaittinen S, Orava S. Proximal Hamstring Tendinopathy: Results of Surgical Management and Histopathologic Findings. The American Journal of Sports Medicine. 2009;37(4):727-734. doi:10.1177/0363546508330129