Top tips for proximal hamstring tendinopathy rehab

Hi all,

Welcome to tendinopathy blog 17.

Quick shout out before we start - places starting to fill for the Lower Limb Tendinopathy Course in Portland, Oregan June 17-18, looking forward to it!

The blog this week (subscribe here) will feature the new narrative review published by Tom Goom et al. on proximal hamstring tendinopathy (check out Tom’s website and blog which is a great resource for clinicians and patients). I assisted Tom along with Mike Reiman and Craig Purdam. Was a pleasure to work with them and Tom has done a great job in translating the limited evidence that is out there, and general principles of tendinopathy management, into a sizable yet enjoyable clinical read! I have invited Tom to join me this week in writing this brief blog highlighting some of the key messages from the review.

Here are some key points, as we see it, from the paper…

• Proximal hamstring tendinopathy is common among runners and other athletes
• Pain is usually localized to the ischial tuberosity
• Pain is often worse with sitting, running, lunging
• Differential diagnosis can be challenging (summarized in the box below)

• The key to diagnosis is ruling out anything that will change your treatment like for example an ischial ramus stress fracture
• But also be aware that many patients do not fit into a diagnostic ‘box’ but may have atypical symptoms
• The most common example of this is referred pain into the hamstring which may well be mechanical sciatic nerve irritation as discussed in the box above
• But it also is commonly simply explained by sensitization and is more consistent with this for many patients eg shifting and spreading pain
• The reassuring thing for clinicians is that once you have ruled out diagnoses that need specific treatments, then the approach is simple…

Let’s summarise the key steps to successful management…

• Address pain by modifying aggravating loads, isometric exercises and adjuncts such as anti-inflammatories
• Establish and address contributing factors including load, biomechanics but also and crucially systemic and cognitive-emotional factors
• Educate, reassure and set expectations – THIS CANNOT BE UNDERESTIMATED!!!
• Education includes (but is not limited to) reducing nocebo related to perceived imaging pathologies (e.g. tears) and the meaning of pain
• Last but not least progressive rehab to develop load tolerance – ie allow the tendon to endure loads it needs to with minimal or no pain during and after
• Everything else is an ‘adjunct’ – often can be very very helpful at the right time but also not indispensable (e.g. manual therapy, injections, etc)

Here are some tips about how you can do the rehab…

• Pain is the best guide – monitor load daily with load tests
• Isometrics we know from the patellar tendon reduces pain and also reverses cortical inhibition (inhibition of the affected muscle) – worth doing throughout rehab
• From here on we are burdened by choice – what really is the best rehab option? Eccentric, concentric, fast, slow, limited or into range, painful or painfree etc, etc
• Rule number 1, take a deep breath and don’t stress about it
• Your number one job is to convey to the patient that you are absolutely in control and know what you are doing (and you do!)
• You see, the specifics probably do not matter as long as you progressively load them and respect load tolerance
• In the paper we discuss slow isotonic load that should be single leg, and should consider some isolated hamstring work like a leg curl, but initially out of hip flexion

• Hip flexion tends to be painful initially, possibly due to more tensile and compressive upper hamstring load
• This slow isotonic load can be progressed into hip flexion once they are load tolerant
• A lot of this rehab has an eccentric component into hip flexion which is important for hamstring function eg in late swing of running
• But we probably do not need to do isolated eccentric rehab

• Impact and faster loads like running are the hardest to return to
• There is debate about how best to do this – basing it mainly on load tolerance and gross function during the task works well
• In the paper we also discuss adequate strength in the isotonic rehab stuff, which is important but for less of a priority than load tolerance
• You can progress from here directly to running, but many athletes require energy storage exercises as shown below to develop power and load tolerance specific to how the hamstring functions in their sport

• Final thing to consider is rehab for the kinetic chain and movement retraining – see paper for more details
• For example, poor lumbopelvic control and excessive anterior pelvic tilt as well as overstride during running may increase upper hamstring load

See it’s not that complex. Of course the devil is in the detail, so please always be conscious of specific diagnostic groups, red flags, and definitely read the full text for more details. But the message from this blog is ‘do the simple things well’, and you are more than half way there!

All the best until next time

Peter Malliaras with special guest Tom Goom