Proximal Hamstring Tendinopathy: Literally a Pain in the Butt

Kelsey Bates, APRN

I think we would all agree that the majority of health care providers are comfortable managing low back pain, neck pain, shoulder pain, knee pain, elbow pain, etc. One musculoskeletal issue that can be equally as painful as the forementioned but may not be “as popular or well versed” as the others is chronic proximal hamstring pain. Proximal hamstring tendinopathies can be misdiagnosed or even missed all together. This is due to a low number of hamstring injuries and variable presentations of the injury. Unfortunately, a delay in treatment results in ongoing pain and potentially periods of disability. So, let’s shed some light on the proximal “hammy,” shall we?

Common Scenario of Chronic Proximal Hamstring Tendinopathy

A patient will typically present with a chief complaint of “butt pain, sciatica, hip pain or leg pain.” They report it’s been going on for a while and is gradually getting worse. The pain is typically at the lower buttock, where the hamstring tendons attach to the ischial tuberosity. Individuals who participate in repetitive movements such as running or biking can feel this pain. It can even occur in individuals who aren’t necessarily physically active and sit for long periods of time. Pain shooting down the leg or high into the buttock could be due to sciatic nerve irritation.

These individuals could have had a prior healed proximal hamstring tear. Old Injuries such as these can cause Injured tendons to become re-inflamed. It could also be, no specific injury ever occurred. It can be related to a chronic degenerative process of the tendons due to mechanical overload and repetitive stretch. This can be caused by overuse, poor lumbar and pelvic stability and weak hamstrings.

Physical Exam

To the human eye everything appears intact. No swelling, redness or bruising is present. Upon palpation, there will often times be pain where the proximal hamstring inserts on the ischial tuberosity. Sometimes there is no pain felt on palpation. Typically range of motion is still within normal limits. Degen (2019) discusses a few orthopedics tests that have moderate to high validity and reliability in diagnosing chronic proximal hamstring tendinopathy:

Puranen-Orava test

Bent-knee stretch test

Fast hamstring-stretch test

Standing heel drag test

Resisted knee flexion with the patient prone

Sometimes the physical exam can reveal a clinical diagnosis. Imaging should be ordered when the exam is not conclusive. Magnetic resonance imaging is the most reliable. Findings on MRI consistent with hamstring tendinopathy include edema at the ischial tuberosity, increased tendon size and peritendinous T2 (highlight of fat and water on MRI) signal.

Treatment for Hamstring Tendinopathy

Consider least invasive treatment options first. This is generally the goal for most musculoskeletal injuries. Typically, by the time a patient gets to a health care provider with hamstring tendinopathy they have already tried NSAIDs. While the NSAID helps, they are just a band aid for the issue, not a fix. Tendinopathies need more than medication as they usually don’t resolve with medication.

The foundational treatment for chronic proximal hamstring tendinopathy is eccentric physiotherapy exercises. Degen (2019) also discusses heavy slow resistance training, a combination of concentric (muscle contracting) and eccentric (muscle lengthening) exercises, being a potential treatment. Further study is needed to evaluate the efficacy of combining these exercise types.

Next on the list of treatment modalities is extracorporeal shock wave (ECSW) therapy as an adjunct to eccentric physiotherapy. I have personally seen patients with various tendinopathies (Achilles, shoulder, hamstring) have great results with this treatment.

Ultrasound-guided corticosteroid injections have been shown to significantly decrease pain scores soon after the injection. However, few patients (<38%) continue to have relief six months after the injection (Degen, 2019).

When to consider surgery

Patients who have disabling pain and who have failed non-invasive measures should consider surgery. Surgical release of the tight tendons of the proximal hamstrings over the nerve have proved to be very effective in providing patients relief and getting them back to sports. Fun fact, the most common hamstring tendon found to be the culprit was the semimembranosus (Degen, 2019).

So, the next time you have a patient come in with pain in the lower buttock definitely add chronic proximal hamstring tendinopathy to your differential diagnosis.

References

Degen R. M. (2019). Proximal hamstring injuries: Management of tendinopathy and avulsion injuries. Current reviews in musculoskeletal medicine, 12(2), 138–146. https://doi.org/10.1007/s12178-019-09541-x

Pourcho, A. (2015, July 1). Chronic High (Proximal) Hamstring Tendinopathy. Sports-Health: Knowledge from Veritas. https://www.sports-health.com/sports-injuries/leg-injuries/chronic-high-proximalhamstring-tendinopathy

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