137. Proximal Hamstring Tendinopathy: Diagnosis and Loading Progression

and how to treat it with load and not link. Hey everybody, this is Kasey Hankins. Welcome to PTs Snacks podcast. If you are listening for the very first time, what you need to know is that this podcast is meant for physical therapists and physical therapist students who are looking to grow your fundamentals in bite-size segments of time.

Now, today what we're gonna do is cover essentially what little bit more insight on tendinopathies in general, but specifically in this area, why it can be such a pain no pun intended to get rid of. So essentially proximal hamstring tendinopathy is a load related, injury at the hamstring origin on the isel tuberosity. 'cause we know a lot of the hamstrings originate from there.

It is most often caused by excessive or poorly progressed tensile and compressive loads, especially when the hip is in hip flexion. So on a tissue level, there is a disorganization of collagen fibers, an increased non collagenous matrix and neurovascular ingrowth. And compression usually happens at the proximal tendon when the hip is flexed and the knee is extended. Such as when in lunging, sprinting drills, or even sitting can cause this, even if your knees are not fully extended.

Now, this is more of a tendon capacity issue, not a tissue length problem. Essentially, what has happened is the environmental demands of what is being asked of the tendon has not kept up with what the tissue is ready to do. And over time can cause problems. So

a Jill Cook has a lot of resources in terms of cook and per dims tendon continuum model. That one's pretty commonly referenced. And then Goom. Etal has an article, clinical review of proximal hamstring tendinopathy in the British Journal Sports Medicine in 2016. So if you wanna check those out more, there's a lot more details. Now in terms of these patients, this is gonna be most common in your distance runners field support athletes, especially during acceleration and deceleration phases.

And some with weightlifters. Especially with deadlift variations. And they're probably gonna complain about deep localized buttock pain, aggravated with sitting, sprinting, lunging, or uphill running. And it may be insidious onset, often chronic more than six weeks, but it could also be correlated to a recent change in their activity. Some can describe it as nerve like due to just the sciatic nerve being very close by. But there won't be any true radicular signs present now.

When we are assessing, we don't wanna assume, oh, they have proximal hamstring tendinopathy. It's good to rule out other things. So you can rule out sciatic nerve irritation, they might have positive neurodynamic testing, like with a straight leg raise or a slump. You can rule out gluteal bursitis, which usually is very correlated to sitting pain, but often responds quickly to offloading referred lumbar pain. So I think it's always good to screen out the back anytime you're looking at something

close to the hip. But seeing if any movements specific to the lumbar region are reproducing their pain PAs the lumbar spine, et cetera, and adductor tendinopathy, which would be more medial and worse with abduction, which is, remember the adductors insert more medial and their job is to adduct the legs. Makes sense.

Now in terms of key tests that we're looking at, it is good to palpate, but just make sure you're communicating with your patient on what you're gonna do and that they're comfortable with that modified slump and long sitting. And what you can do is basically put the hamstring on more of a stretch. Passive hip flexion and knee extension. See if that is going to increase their pain and where it increases their pain. And looking at how well they tolerate activation of their hamstrings essentially.

Do they have pain localized at the insertion point? Do they have pain with a stretch to the hamstrings at the insertion point? And are they having pain with usage of the hamstrings at the insertion point? This all kind of correlates, right? Now in terms of why we don't necessarily do a lot of stretching is we're already adding a compressive load on a already sensitized proximal tendon, especially if we're putting them in passive hip flexion and knee extension.

You're just amplifying the compressive tensile stress. Now there's not really any randomized controlled trials

that I've seen. If you have seen it, you can send it my way, but that support stretching for tendinopathy as a primary intervention, while maybe for some people it can feel good, we're probably gonna benefit more from a load based program where they, we are building tolerance to load stress compression, et cetera. So in terms of what that looks like in terms of loading, we know that progressive tendon loading helps to improve. The collagen alignment, motor unit recruitment and tendon capacity.

So the initial goal, and I'm sure the patient would really appreciate this, is to reduce pain sensitivity and improve isometric tolerance. So contracting and holding, and then restore force capacity. So in a phase one, let's say very early on in the treatment with our patient, we'll probably start with some sort of isometric.

Again, this can vary patient to patient or on, keep in mind the research might change down the road, but essentially what we're doing is basically using isometrics to help allow the tendon, that insertion point, to accept load without adding a big stretch or stress. So just that. Keeping that length the same throughout the whole time can help the mechanoreceptors in the tendon to basically send a message up to say, Hey. Here's a signal. Let's dampen the signal.

Let's have a cortical inhibition moment where they have some pain relief. So examples can be like supine, long lever bridges with their heels elevated. Reverse planks with bent knees if they can tolerate it. And a lot of times with tendon loading in the lower body, I'll see a lot of times in research aiming for five reps of 30 to 45 second holds, keeping their pain at a three or less. Or if your patient is not good with numbers just basically trying to make them not

look like they're visibly in pain. Words can be descriptive too, like more than a little. It just depends on the patient in front of you and what's gonna help set them up for success. So now let's say we're able to increase our sensitivity and you can monitor the day after you're loading them to see how well they're tolerating it, how well they feel. Then we're moving on to isotonics. So heavier load that is sub maximal.

And that could be like where they're laying supine, doing hamstring flexion with resistance, so they're not in a compressive state. You can work them towards step ups, Romanian deadlifts. Romanian deadlifts are pretty intense, so they're probably gonna have to work their way up there. But then we're gonna work them towards more of a phase three energy storage in spring. So now maybe they've. Mastered the strength training portion, eccentric hamstring strength, et cetera.

And they're working more towards bounding, skipping, resisted SPRs, et cetera. So these are to be reintroduced in pain-free patients with strong isometric capacity, and they are already tolerant to eccentric loading before we're adding. Sprints to the picture. And then finally, phase four as appropriate, they're going back to sport, working them more towards full sport or high load demands, helping them to get the volume progression back, et cetera.

Depending on the intensity of the pain to begin with. For some recreational athletes, it could be anywhere from two to three months, depending on if they don't really need to go back to something super intense. If they're a runner or a field athlete, it could be at least four months or more, depending on the severity and load goals how quickly they come in to see you and has it been going on for a month or. Five years, that's totally different.

But you are monitoring their pain scale and their strength capacity and making sure that you are utilizing your knowledge of tendon rehab with the patient that is in front of you. Remember this is not medical advice and this is just a summary. It's hard to generalize something and make it specific to one person. Just keep that in mind. But essentially. What we wanna be mindful of with proximal handr tendinopathy is being mindful of how much compressive load and lengthening load

we're adding early on. But eventually getting them to be able to tolerate that so they can be able to get back to sprinting and heavy weight training and stuff like that. Use a progressive loading system. Start with isometric, start to work towards isotonics to improve tendon capacity, and then work on energy storage and release.

If you have been listening to this show and you've gotten a lot of value from them, or if you've listened to at least three, if you wouldn't mind leaving a review on this podcast wherever you listen to podcasts, that would really help quite a bit.

I. Now if you wanna take a deeper dive and you already have a Med Bridge subscription or you're thinking about getting one, a few courses that might be helpful for you just to get more information would be lower extremity tendinopathy, evaluation and management with Dr. Travis Pollen. Rehabilitation of hamstring injuries with Dr. Christian Thorberg and the tendon.

Continuum with Dr. Jill Cook would all be really great options to go with if you have not gotten a Med Bridge subscription yet, but want to get a huge discount, meaning like over a hundred dollars off Med Bridge is actually a sponsor of the show and they're giving listeners over a hundred dollars off. If you are interested in a platform that has. Tons and tons of CEU courses, webinars, specialty exam prep courses. You should definitely check it out. No pressure.

But they have some good stuff on there. So that's it for today guys, and if you have any questions, feel free to reach out at pt Snacks podcast@gmail.com. Otherwise, I hope you have a great rest of your day and next time.