Proximal Hamstring Tendinopathy- Introduction

Great blogpost by the guys from Evidence Based Movement about proximal hamstring tendinopathy! 🙂
They share some good quality information and video’s.

 

Evidence Based Movement (EBM), are current 3rd year Doctoral of Physical Therapy students that reside in the United States. The focus of our page is simplify current scientific research, as it relates to orthopedic and athletic populations, with the goal of helping you better understand it to then apply it appropriately to your patient population. Please feel free to follow us on Instagram @evidencebasedmvmt.

 

Proximal hamstring tendinopathy (or PHT) is pain that is often described in the deep buttocks, and commonly localized to the area of the ischial tuberosity, which may radiate down the posterior thigh (Cushman & Monica, 2015). It is frequently found in distance runners, athletes that function in the sagittal plane (i.e. sprinters), as well as athletes who commonly perform changes in direction during sport (Groom et al 2016).

A key characteristic of PHT is that the pain often gets better with a few minutes of activity (such as during a warm-up) BUT then gets worse during or after activities such as running (e.g. during the later portion of the swing phase), lunging, squatting and/or sitting, especially if performed on harder surfaces (Groom et al 2016). Symptoms may also occur during forward trunk bending, hip extension, and/or knee flexion (Cushman & Monica, 2015).

PHT is thought to commonly occur without any sort of trauma and progressively becomes worse over time (Lempainen et al 2015). Hypothesized mechanisms include increasing training volume too quickly, excessive static stretching (such as those found in yoga or Pilates poses that require end-range hip flexion) or simply sitting for long periods of time (due to a compression load) (Groom et al 2016).

 

Special thanks to Dr. Michael P. Reiman, DPT, OCS, SCS, ATC, FAAOMPT, CSCS for helping film this introduction video

 

 

 

Rehab Stage 1 – Isometric Hamstring Load

According to Cook et al (2014), resisted isometrics without tendon compression is beneficial for loading muscle AND decreasing tendinopathy symptoms. To support such thinking, a study by Rio et al (2014) demonstrated improvements in patellar tendon pain for a minimum of 45 min after performing 5 sets of 45s holds of moderate intensity isometrics. The later study also identified that isometrics were better for pain relief when compared to isotonic exercise. An appropriate exercise for the following stage is the single-leg glute bridge with hold, which is described as follows….

 

1. Begin supine with your feet flat and knees bent
2. Push through your heels to raise your hips off the ground
3. Once your hips are off the ground, extend the non-involved leg out (so that the foot of the involved leg is still on the ground)
4.       Hold the following position for as long as possible (keeping your hips leveled)
5. Return the non-involved leg to the ground and repeat for as many repetitions as deemed appropriate

 

Groom, T., Malliaras, P., Reiman, M., & Purdam, C. (2016). Proximal Hamstring Tendinopathy: Clinical Aspects of Assessment and Management. JOSPT, 46 (6), 483 – 493.

 

 

Rehab Stage 2 – Isotonic Hamstring Load with Minimal Hip Flexion

In the following stage, the goal is to incorporate exercises that begin to strengthen the hamstrings in a functional range YET protect the proximal hamstring tendon. An appropriate exercise for stage 2 is the Nordic Hamstring Curl (both half and full variations). The following exercise(s) is (are) a form of heavy, slow resistance training which has shown to better improve pain and function in those with Achilles tendinopathy when compared to isolated eccentrics (a common form of exercise for tendinopathy) (Beyer et al 2015). Both half and full variations of the Nordic Hamstring Curl are described as follows…

 

Nordic Hamstring Curl – Half

1. Begin in a high kneeling position with your hands out in front of you

!! This variation SHOULD be done with a partner

2. Slowly lower yourself in a controlled manner until you feel that you CANNOT go any further
3. Once reaching end point, drop to the ground and catch yourself with your hands (making SURE that your back STAYS FLAT throughout the entire exercise)
4. Push yourself back up with your hands, NOT by pulling with your hamstrings
5. Repeat for as many repetitions as deemed appropriate

*Stage 2 exercises should be performed every other day

 

 

 

Nordic Hamstring Curl – Full

1. Begin in a high kneeling position with your hands out in front of you

!! Unlike the previous variation, if a partner is NOT present then secure your ankles underneath a lat pulldown pad to perform the following variation

2. Slowly lower yourself in a controlled manner until you feel that you CANNOT go any further
3. Once reaching end point, fire your hamstring to pull yourself back up to the starting position (making sure to NOT let yourself touch the ground)

!! To progress this exercise, hold yourself at end point for a desired amount of time

4. Repeat for as many repetitions as deemed appropriate

*Stage 2 exercises should be performed every other day

 

Groom, T., Malliaras, P., Reiman, M., & Purdam, C. (2016). Proximal Hamstring Tendinopathy: Clinical Aspects of Assessment and Management. JOSPT, 46 (6), 483 – 493.

 

 

Rehab Stage 3 – Isotonic Exercise in Positions of Increased Hip Flexion
The goal of stage 2 was to incorporate exercises that begin to strengthen the hamstrings in a functional range YET protect the proximal hamstring tendon. The focus in stage 3 is to continue to strengthen the hamstring musculature WHILE increasing into greater ranges of hip flexion. Greater hip flexion stresses the proximal hamstring tendon more to better prepare the hamstrings to return to full functional activities. An appropriate exercise for the following stage is the single-leg RDL (Romanian Deadlift) with a Kettlebell, which is described as follows….

 

1. Begin standing grasping the kettlebell (so that elbows are pointing out to the side)
2. Lower the kettlebell in a controlled manner by hinging at your hips AND driving your butt back as far as possible (listed below are a few cues from Tony Gentilcore)

!! Throughout the entire exercise, keep your neck AND back in a neutral position (think of making your spine LONG)

!! As to the standing (or supporting) leg, maintain a “soft knee” by flexing slightly (Tony Gentilcore recommends between 15-20°)

!! As to the moving leg, drive your heel up towards the ceiling (at this point, you should feel your weight shift onto the heel of your standing leg)

3. At end point (i.e. the point where you feel that you CANNOT push your hips back any further), pull yourself back up by extending at the hips
4. Repeat for as many repetitions as deemed appropriate

*Stage 3 exercises should be performed every other day

 

 

Groom, T., Malliaras, P., Reiman, M., & Purdam, C. (2016). Proximal Hamstring Tendinopathy: Clinical Aspects of Assessment and Management. JOSPT, 46 (6), 483 – 493.

 

 

Rehab Stage 4 – Energy Storage Loading
Before returning to play, athletes should be able to meet the demands of their respective sport. For a majority of athletes, this involves the ability to transfer high levels of load quickly as well as accurately. Therefore, incorporating plyometrics and agility drills are appropriate strategies to help establish a functional return to play protocol. It should be noted that the following stage is ONLY needed for athletes requiring those demands described above. With that being said, an appropriate exercise for the following stage is the cycled split squat jump, which is described as follows….

 

1. Begin in a forward lunge position
2. Explosively jump up (using your arms as needed to assist)

!! While in mid air, switch your leg position (so that your leg that was in front at the beginning of the exercise is now in back and vice-versa)

3. Upon landing, maintain a lunge position AND immediately explode back up

!! When landing, AVOID your back knee touching the ground as well as your knees caving (or buckling) in

*Stage 4 exercises should be performed every third day

 

Groom, T., Malliaras, P., Reiman, M., & Purdam, C. (2016). Proximal Hamstring Tendinopathy: Clinical Aspects of Assessment and Management. JOSPT, 46 (6), 483 – 493.