Proximal Hamstring Tendinopathy
Proximal hamstring tendinopathy can be a frustrating condition to deal with. It typically presents as pain on the upper portion of the hamstring and is worse with activities that require hip flexion such as walking, running, squatting, and lunging. This post will discuss the anatomy, pathology, and rehabilitation for proximal hamstring tendinopathy.
Proximal Hamstring Anatomy
The hamstrings consist of 3 different muscles: biceps femoris, semitendinosus, and semimembranous. The biceps femoris is on the lateral aspect of the thigh (outside portion) whereas the semimembranous and semitendinosus are on the medial aspect (inside portion).
As the hamstrings attach onto the pelvis through the ischial tuberosity, the biceps femoris muscle and semitendinosus muscle join together on the medial portion of the ischial tuberosity. The semimembranosus muscle attaches onto the lateral portion. While the hamstrings are known to flex the knee, the proximal portion works to extend the hip.
Proximal Hamstring Tendon Pathology
Overloading of the hamstring tendon is thought to be the primary driver of proximal hamstring tendinopathy. Essentially the loads placed on the hamstring tendon are more than they can tolerate.
With this being said, the anatomy of the proximal hamstring tendon may have an influence on the pathology. Since the tendon wraps around the ischial tuberosity, compression may also lead to irritation of the tendon. Movements with hip flexion will compress the tendon. Examples include squats, lunges, uphill running, and sprinting.
Proximal Hamstring Tendinopathy Rehabilitation
The rehabilitation of proximal hamstring tendinopathy occurs in a similar 3 step progression: isometric loading, concentric/eccentric loading, and plyometric loading.
Isometric exercises
Initially with isometric loading, the goal is to begin loading with minimal hip flexion to avoid compressing the hamstring tendon against the bone.
A long lever bridge can be used for initial isometric loading to achieve this. To perform, the heels will be placed as far away from the body as possible and then lift the pelvis off of the ground. This position should then be held for 30 to 45 seconds and repeated for 3 to 5 repetitions.
Ebonie Rio had demonstrated that heavy isometric exercises had a pain relieving effect for the patellar tendon. However, this has not been demonstrated for other tendons which has lead to a debate of whether isometric contractions should be used for tendinopathy rehabilitation. There is little downside to including isometric in the rehabilitation of tendinopathy. They can serve as a beginning loading progression that can be used especially for irritated tendons. If they provide an analgesic effect, obviously that would be an additional benefit.
Isometric exercises may not provide a pain relieving effect, however, there is little downside to including them into a rehab program.
Concentric-Eccentric exercises
After isometric loading, the rehabilitation program progresses to concentric and eccentric loading. While eccentric exercises have dominated the rehabilitation programs for tendinopathy, it doesn’t appear to be necessary to isolate the eccentric muscle contraction according to a systematic review by Peter Mallarias.
There are many options for loading the proximal hamstring for concentric-eccentric contractions. A simple progression from the long lever bridge is to place the feet on an elevated surface and perform long lever bridges by slowly lifting the hips off of the ground. It is possible to integrate a heavy, slow resistance protocol for the proximal hamstring by performing these muscle contractions over a 3 to 4 contraction in each phase.
Eccentric exercises have dominated the rehab for tendinopathy. However, it doesn't appear to be necessary to isolate the eccentric muscle contraction for an effective rehab approach.
The loading progression can then progress to banded pull thrus, deadlift variations, and single leg pulls. From a technique point of view, it is important to try to maintain a neutral pelvis during these exercises. An anterior pelvic tilt during rehab these exercises may lead to additional compression on the tendon during the rehab process. As the tendon’s tolerance to compression increases, the emphasis on minimizing an anterior pelvic tilt becomes less important.
Plyometric Exercises
The final phase of a rehabilitation program is plyometric exercises. For most this phase is not important or necessary. But for those returning to a sport, this is an important phase for minimizing the risk of re-injury. Plyometrics expose the tendon to sudden loads which will most similarly replicate the loads that are experienced during sport. Exercises that can be used during this phase include skipping, squat jumps, and jumping lunges.
Because plyometric exercises place a high load on the tendon, it is important to allow adequate recovery after each plyometric session. Typically it takes the collagen in the tendon 48-72 hours to adapt to these loads. Therefore, 2 to 3 days in between plyometric sessions is advised. Concentric-eccentric strengthening exercises can be performed on the days between plyometric sessions.
Gait Modifications
While the rehabilitation program for a proximal hamstring tendinopathy should focus on increasing the tolerance of the tendon to load, there are other biomechanical considerations that should be addressed during the rehab process as well.
The activation of the glutes and core while running is one consideration for those with proximal hamstring tendinopathy. Research has found that those with proximal hamstring tendinopathy have reduced gluteal activation. This would decrease the hip extension force generated while running, placing a higher demand on the proximal hamstring to extend the hip. Therefore, training gluteal activation for hip extension during running could be beneficial.
Along with the hip extension movement pattern, overstriding may also be an issue for those with proximal hamstring tendinopathy. Overstriding occurs when the foot lands too far in front of the body while running. Instead of the glutes and quads extending the hip and knee to create a push during running, the hamstrings would work to pull the body forward while running. This overstriding could have been present before the development of proximal hamstring tendinopathy or developed as a result of the reduced glute force mentioned above. Either way, gait retraining before returning to sport would be helpful for recovery and prevention.
Summary
The primary treatment strategy for proximal hamstring tendinopathy is a progressive rehabilitation strategy, generally progressing from isometric loading, to concentric-eccentric, and finally plyometric exercises. Additionally, biomechanical modifications may help in the recovery process. Although proximal hamstring tendinopathy can be a stubborn and frustrating condition, exercise can help in the recovery process.
Key Points
- Overload is a contributor to tendon pathology but compressive load is an important consideration for proximal hamstring tendinopathy.
- A gradual loading progression is the primary treatment approach for PHT.
- The type of muscle contraction may not matter as much as the intensity of load on the proximal hamstring.