Hamstring injuries are some of the most common injuries in sport.

The best indicator of hamstring injury is a previous hamstring injury.

And many have limited success in reducing the rate of hamstring re-injury.

They can be challenging and frustrating because of the high recurrence rate.

A possible reason for this is due to lack of education and the incorrect implementation of treatment modalities.

80 % of some tendinopathies recover with exercise therapy alone.

Research shows that athletes who have sustained a hamstring injury (strain) lack muscle strength when the muscle is utilized during performance in a lengthened state.

 

In this article, we aim to educate and hopefully inspire you to implement the correct treatment modalities. We will discuss what hamstring tendinopathy is, how to know if you have it, what the causes are, how to treat it and how to prevent it from re-occurring.

What is hamstring tendinopathy?

To answer this we need to know what a tendon is: It is a structure composed of collagen / connective tissue. It connects muscle to bone and acts like a pulley. When you contract the muscle it pulls on the tendon which in turn pulls on the bone. Thus, allowing you to move the joint or segment of your body.

Tendinopathy – A previously accepted concept was that tendinopathy was chronic inflammation of the tendon. However, more recent research is showing that it is actually the absence of chronic inflammation and rather a failed adaptive response to load in a chronic manner.

What does this mean? Well, this means that your tendon is not inflamed. It means your tendon was doing too much work relative to its strength. When the tendon is overloaded for a prolonged period, the tissues deteriorate and loses its normal function. The tendon undergoes degeneration leading to fibre disorientation and is eventually replaced by other connective tissue. Hamstring tendinopathy occurs when there is excessive or unusual loading of the muscle.

Correct forces strengthen and incorrect forces destruct

 

Other factors that can contribute to the overload or overuse injury:

1. Training errors, such as increasing volume or intensity too quickly, particularly the sudden introduction of sprinting, lunging, hurdles, or hills
2. Excessive use of static stretches, for example, yoga and Pilates postures that involve sustained end-range hip flexion
3. Compressive load from sitting
4. Upright / uphill running can be an aggravating factor
5. Poor form / technique during activities
6. Muscle imbalance between quadriceps and hamstrings muscles
7. Biomechanical deficiencies / weakness in other areas
8. Muscle fatigue during heavy load training
9. Faulty posture
10. Leg length discrepency
11. Tight hamstrings

 

 

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3 different classifications of hamstring tendinopathy:

This is important to know as each classification might be treated differently and have different healing criteria.

1. Reactive tendinopathy
2. Tendon disrepair
3. Degenerative tendinopathy

How can you know if you have hamstring tendinopathy?

A clinical healthcare practitioner will have to diagnose you, but in most cases you will have localized pain in the region between your buttocks and back of the leg that often worsens during or after activity. There are various ways of doing this. Initially a clinical history taking in conjuction with a movement diagnosis and pain pattern can be evaluated by a biokineticist or physiotherapist. Taking a clear history of your pain and injury is vital to understand what the cause for your tendinopathy might be. Have you changed equipment, training programs, surfaces, traumatic event, taking antibiotics etc.

Furthemore, the diagnosis should include assessment of joint range of motion, strength, coordination, and functional tasks and should be related to individuals’ sport and activities of daily living. The more sports-specific and movement-pattern specific the
assessment can be, the better. Additionally, various load test and stretch assessments may be performed to diagnose hamstring tendinopathy.

Other avenues the therapist might pursue to diagnose (if evaluation is not clear), is referral for a ultrasound sonar, x-ray or other investigations i.e. MRI. In most cases there is a thickening of the tendon that can be seen and a report will be clear on the diagnoses and whether you have tendinopathy or not.

Tale tell signs of hamstring tendinopathy:

• Classic tendon pain behavior includes  well-localized ischial tuberosity pain that becomes less symptomatic after a few minutes of activity (i.e, warm-ups when running) but is worse afterward.

 

Treatment modalities

The focus of treatment in early presentation should be on managing pain. This might include modifying training, visiting a  biokineticist / physiotherapist and taking medications if it is so advised. It is also quite common for more chronic pain to not only present with isolated hamstring pathology/injury but may co-exist with other pathologies. This may further complicate treatment and prolong management.

The normal treatment protocol for hamstring tendinopathies is ± 3-6 months. BUT, the key to management of all tendinopathies is progressive loading. Progression through the stages should be based on patient reported symptoms and responses to exercise loads, rather than a specific time frame. This is because there is considerable individual variation of pain and functional deficits.

 

1. Biokinetics – exercise therapy
   • Specific 4-stage tendinopathy protocol
   • Graded loading exercise program  
   • Rehabilitation exercises & stretching / mobility work
   • Load modification and management
   • Reduce aggravating activities
   • Increase relieving loads
   • Manage and monitor for deterioration
   • Graded return to sport protocol
   • 80 % of patients with achilles tendinopathy recover with exercise alone
2. Physiotherapy
   • Dry needling
   • Soft tissue techniques
   • Shock wave therapy
   • Other modailities to reduce pain
   • The above mentioned passive interventions are unlikely to improve tissue load capacity, which is a key element of tendinopathy rehabilitation
3. Rest
   • Rest is good for reactive tendinopathy BUT does not resolve the tendinopathy. Managing your load on the tendon is more important than only resting.
4.  Orthosis
   • It is good to sometimes off-load the tendon with orthosis if possible i.e. achilles tendinopathy.
5. Medication / injections
   • Anti-inflammatory medication (i.e, Ibuprofen) has been suggested for settling irritable tendon pain. Nonsteroidal anti-inflammatory drugs might compromise tendon healing but is not fully understood as of yet.
   • Research suggests some of the following guidelines when it comes to Platelet-rich Plasma (PRP) and cortisone.
   • Cortisone might be suggested by your sports doctor or physician to take away your pain while you sort out your biomechanics (exercise technique + load etc). Corticosteroid injections may provide short-term pain relief, but symptoms have a tendency to re-occur.
   • Some tendons don’t do well with cortisone – Achilles don’t like cortisone. However, cortisone was previously the choice of treatment, but since then it has been proven that not all tendons do well with cortisone especially when implemented in a chronic manner – and it does not deal with the cause of the tendinopathy (incorrect / overload).
   • Platelet-rich therapies (PRP), autologous blood, and other agents may be suggested in more chronic injuries. Most elbows do well with PRP injections especially when combined with exercise therapy.
   • Greater Trochanteric Bursitis also does well with PRP, especially when there is a tear too.
   • There are other medications that might be prescribed, but again remember to deal with the cause and not just the pain.
6. Surgery
   • This is the least conservative option and should only be considered when and if conservative treatment (biokinetics, physiotherapy, orthosis, medicine etc) has failed.

Most common types of other tendinopathies:

1. Hamstring tendinopathy
2. Patellar tendinopathy – Jumper’s knee
3. Achilles tendinopathy
4. Tennis elbow
5. Golfer’s elbow

 

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Credits to images used in this article:

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