Proximal Hamstring Tendinopathy, Assessment and Management

By: Helen Feeney, Chartered Physiotherapist and Certified Pilates Instructor at APPI, Wimbledon.

Date: 9^th April 2019.

Prior to starting my role at APPI, myself and a few friends signed up for the Wimbledon half marathon. To say it was an undulating run was an understatement, particularly for someone who had been training on the flat concrete jungle of East London. Soon after this great race, I developed pain around the back of my left thigh. This persisted for months and prevented me from running and even walking for periods greater than half an hour. It was only when I sought the expert advice of Benoy Mathew at Harley Street Physiotherapy that I was diagnosed with Proximal hamstring tendinopthy and started on a tendon loading programme that my pain started to subside.

Proximal Hamstring Tendinopathy (PHT) is common in athletes, particularly distance runners, sprinters and those whose sport involves change of direction such as football. It can also affect to non- sporting demographic for example peri- menopausal females where the symptoms are often bilateral (Malliaris, 2014)

Tendons are an area of special interest to me and so I wanted to share with you my top tips on the assessment and management of PHT. Much of the material has been adapted from a paper by Goom et al (2016) in the only publication of its kind to date on the assessment and management of PHT.

The outcome and prognosis are dependent on an accurate diagnosis and subsequent management. Diagnosis is based on a thorough subjective history and objective examination.

Subjective history:

Pain with positions of deep hip flexion i.e. squat/ lunge
Sitting on hard surface
Walking/ running up hills, sprints, hurdles

Objective findings:

Local pain at the Ischial Tuberosity/ seat bone
Functional tests (short, long lever shoulder bridge, arabesque)
Gait/ running analysis (over stride, heavy heel strike, lack of terminal hip extension, reduced anterior pelvic tilt control)
Kinetic chain considerations
Special Tests: +ive Puranen- Oravo Test/ Bent / Modified Bent Knee Stretch

Management:

Points to consider for successful management (taken from presentation delivered by Benoy Mathew).

Educate, reassure and set expectations.
Address pain- modify aggravating factors, NSAID’s, isometrics.
Reduce load and modify activity in reactive stage.
Load progressively (isometric, isotonic, concentric, eccentric, plyometric, sport).
VAS 3-4/10 during exercise
Pain provocation is ok if no longer than 24 hours (stable) > 24 hrs (irritable)
Determining irritability and load management; Establish a) what activities increase symptoms B) for how long?
Exercising with PHT: Often it is not essential to stop everything. Cycling can be done in standing (reduces hip flexion angle), water running and swimming are good alternatives to more provocative exercises.

Once the diagnosis has been confirmed and other differential diagnoses such as referral from the back or nerve pain (a common co-morbidity) or Ischio-femoral impingement have been excluded, a progressive loading rehabilitation programme can commence. My experience in both the receiving and delivering of PHT rehab has facilitated me in devising a rehab programme which draws on my skills as a Certified Pilates instructor and Chartered Physiotherapist, to include mat and reformer bases exercises. I have shared some of these with you on Table 1 below.

Stage of Rehab	Floor	Reformer
First Stage: Isometric load (without compression initially)Neutral hip- 30 flexion max Ex prescription:Isometrics: 70% MVC 5 sets of 45 sec holdX 3-4/ day Isotonic:Slow isotonic concentric eccentric loading 30 – 40 reps over 4-5 sets	Shoulder bridge-Isometric:(start with isometrics due to pain inhibitory response)Long lever shoulder bridge (double to single leg) Isotonic: Trunk extension over ball	Shoulder bridge isometric- Isotonic, Long lever shoulder bridge on low-mid bar.a) bar down – knees bent to 30 degrees to start.b) low bar, legs extended. Long box trunk extension arms on bar facing front (1B)Arms Pulling straps facing rear- plough with extension.
Second Stage:Increase hip flexion range (70-90 degrees) Ex prescription:Every second day (guided by 24 hour pain response to exercise/ provocative clinical tests)	Deadlift (5 x 6) Kinetic chain: Gym ball tucks (4 x 8) TheraBand adductors	Stand on carriage facing rear, hands in straps*both feet on carriage!(1R, 1Y. Trunk 30/45/90-degree flex. Hands at trunk to start then progress to plough arms to challenge. Modified plank on high bar facing front, carriage in & out(add single leg/ add pike- modify resistance) 1R Plie 1YPlie carriage in & out
Third Stage:Indicated for those returning to sports requiring lower limb energy storage Ex. Prescription: Ex prescription:Every third day, followed by stage 1 exercise to settle tendon followed by stage two exercise= 3 day high- low- medium tendon load cycles.X 2 / week plus rest day between cycles	Alternate leg split squats	Back facing lunge, one foot on floor, one on carriage.a) push carriage away (carriage knee flexion and extension with floor knee bent)b) add knee bend with foot in plantarflexion

As a general rule progression to the next stage of rehab is indicated using the following:

Subjective markers:

Monitor pain in response to loading at the same time each day i.e. single leg shoulder bridge/ long lever bridge/ Arabesque.
*VAS / pain 0-3/10 is ok during and after exercise
Symptoms should settle within 24 hours

Outcome measure:

VISA (The Victorian Institute of Sport Assessment) pain and function outcome questionnaire is the recommended outcome measure. (1).

First stage of rehab is divided into isometric and isotonic loading.

Loaded hip flexion is minimised to protect the enthesis against compressive stimulus so we stick to hip flexion range from neutral to 30 degrees.

Success criteria to move from 1^st to 2^nd stage:

Progress to second stage when there is minimal pain or VAS 0-3/10 24 hours after first stage exercises.
Caution with progression to increased hip flexion ranges as this can be provocative. Monitor 24 hour response to loading with hamstring testing into hip flexion i.e. single leg shoulder bridge.

Second Stage: hip flexion 70-90 degrees.

Goal is to build strength and hypertrophy in functional positions (i.e deep lunge for hockey player) while progressing to greater hip flexion. Commence this training when VAS 0-3/10 with higher loading hip flexion tests such as lunge or arabesque or functional ranges for athletes sport.

Success criteria to move from 2^nd to 3^rd stage:

Progress to third stage when there is minimal pain (VAS 0-3/10) 24 hours after second stage exercises.
Monitor pain in response to loading at the same time each day i.e. Arabesque, deadlift.

Third Stage:

Energy storage loading. Required for those returning to sports requiring high impact. Commence when VAS 0-3/10 with high load functional test such as arabesque. Must be able to demonstrate equal strength to unaffected side when performing middle stage unilateral exercise. This is a provocative stage therefore perform every third day. This should be followed by an early stage isometric loading day, followed by an intermediate stage loading day. A rest day is allowed between cycles.

Kinetic chain considerations:

Adductors strength and function esp. adductor magnus. Is a significant hip extensor and its muscle fibres are intimately related to the origin of semimembranosus
Over stride: Increases load on hamstring origin tendons (so does excessive forward trunk lean and anterior pelvic tilt). Increasing cadence/ step rate reduces stride length and hip flexion at foot strike and increases gluteal activity in terminal swing

*VAS rating of provocative functional tests within session i.e Single leg bent knee bridge- low load test/ single leg long lever bridge- mod load test/ Arabesque/ single leg deadlift- high load test is preferable for immediate symptom response to exercise. A stable hamstring may be able to sprint for 20 min before pain kicks in and another hamstring may become painful after ten minutes of sitting. We use this information to guide your exercise prescription and rehab progression.

References:

Cacchio et al. Development and validation of a new VISA Questionnaire (VI-SA-H) for patients with proximall hamstring tendinopathy. Br J Sports Med. 2014; 48: 448-452. http://dx.doi.org/10.1136/bjsports-2012-091552

Chumanov ES et al. Changes in muscle activation patterns when running step rate is increased. Gait posture. 2012; 36; 231-235. http://dx.doi.org/10.1016/j.gaitpost. 2012.02.023

Goom. T., Malliaris., P. Reiman M., Purdam C. Proximal Hamstring Tendinopathy: Clinical Aspects of Assessment and Management. Journal of Orthopaedic and Sports Physical Therapy. (2016). 46; 6; 483-493.

Malliaris., P. & Purdam., C. Feature: Proximal Hamstring Tendinopathy Assessment and Management. Sport Health. 2014; 32:1: 21-29.

PHT: clinical aspects of ax and mx published in by Goom/ Malliaris and co in 2016.