Expert opinion: diagnosis and treatment of proximal hamstring tendinopathy

Abstract

IntroductionProblems related to hamstring muscles and tendons range from benign hamstring strain injuries to severe total 3-tendon ruptures 1 . Acute hamstring injuries are well documented in literature but chronic pains and problems are not as well known. In this expert opinion paper, we reviewed the literature on proximal hamstring tendinopathy (PHT) through literature search of scientific journal databases. Despite different anatomy there are similarities to tendinopathies of other tendons in regards of chronicity, disabilitation and histology. In other tendons the clinical presentation of painful swelling impairing performance is defined as tendinopathy and more specific diagnoses such as tendinosis are specified after surgery and histological investigation 2 . PHT should be regarded similarly, a clinical diagnosis which can be specified through operative and histological investigation. Diagnostic features as well as both operative and non-operative treatments are evaluated from a clinical perspective, providing up to date information for clinicians and sports medicine therapists dealing with hamstring problems. This article submits to the ethical standards of the journal 3 . Pathogenesis and predisposition factorsWhat we know about the pathology of PHT is limited to few studies. Histopathological samples from proximal hamstring tendons have shown rounding of fibrocyte cell nuclei, increased amount of extracellular matrix, disruption of normal collagen structure and neovascularisation including observations of fatty degeneration 4 . The microscopical histology is the same as the histology that defines tendinosis in other weight bearing tendons such as the Achilles and patellar tendons 5,6 . Currently many endogenous mediators induced by thermal, mechanical, vascular or neuronal stimuli are investigated in the pursuit of the

Posterior, Lateral, and Anterior Hip Pain Due to Musculoskeletal Origin: A Narrative Literature Review of History, Physical Examination, and Diagnostic Imaging

“…32,33 Peripheral neuropathy tests should be negative, and rarely are there any strength deficits with knee flexion or hip extension. 33 Both US and MRI can be used to diagnose proximal hamstring tendinopathy, with MRI currently considered more sensitive than US and better suited for a broader range of body types. 35 On MRI, symptomatic proximal hamstring tendons demonstrate significant increases in width and thickness, peritendinous high T2-weighted signal with a feathery appearance, and ischial tuberosity edema.…”

“…31,32 The clinical features of proximal hamstring tendinopathy include previous injury, pain during activity, and pain with prolonged sitting. [32][33][34] The clinical examination may reveal tenderness or pain elicited with palpation, muscular defect over the ischial tuberosity against resisted knee flexion or hip extension, and pain with passive stretching of the muscle. 32,33 Peripheral neuropathy tests should be negative, and rarely are there any strength deficits with knee flexion or hip extension.…”

“…[32][33][34] The clinical examination may reveal tenderness or pain elicited with palpation, muscular defect over the ischial tuberosity against resisted knee flexion or hip extension, and pain with passive stretching of the muscle. 32,33 Peripheral neuropathy tests should be negative, and rarely are there any strength deficits with knee flexion or hip extension. 33 Both US and MRI can be used to diagnose proximal hamstring tendinopathy, with MRI currently considered more sensitive than US and better suited for a broader range of body types.…”

Treatment of proximal hamstring tendinopathyrelated sciatic nerve entrapment: presentation of an ultrasound-guided �Intratissue Percutaneous Electrolysis� application

“…PHT is clinically characterised by pain in the subgluteal region, at the proximal insertion of the hamstring muscles onto the ischial tuberosity, with possible radiation to the posterior region of the thigh; sprinting and sitting for long periods are the activities in which the symptoms are typically exacerbated 1,2 . The proximal insertion of the semimembranosus (SM) muscle onto the ischial tuberosity is superior-lateral, relative to the insertion of the conjoint tendon of the biceps femoris and semintendinosus.…”

“…One scenario that can occur is that symptoms related to tendinopathy recede, while those derived from irritation of the SN persist. Surgical treatment for managing PHT involves tenotomy of the SM tendon, which is sutured to the tendon of the biceps femoris [1][2] . The positive outcome of SM tenotomy is that the SN is anatomically unbridled from the tendon; the intervention is therefore also valid for the treatment of PHTrSNE.…”