Lionel Pannunzio PT / SCS
Proximal Hamstring Tendinopathy in Soccer Players, a deep pain in the buttocks area...
Proximal hamstring tendinopathy (PHT) is commonly seen in long distance runners and athletes taking part in sprinting or hurdles. .
It is also common among athletes taking part in sports such as soccer , football and hockey, which involves a change of direction activities.
What is Proximal Hamstring Tendinopathy ?
Proximal hamstring tendinopathy is also referred to as High hamstring tendinopathy.
It is characterized by deep, localized pain in the region of the ischial tuberosity.
Pain is usually worse during or after activities such as running, lunging, squatting .
This condition can include tendon degeneration, partial tearing and peritendinous inflammatory reactions.
The junction between the tendons of the hamstrings and the ischial tuberosity is the area affected by high hamstring tendinopathy.
The tendon’s thickness, fibrousness and poor blood supply are the causes of difficult healing
Symptoms - How does it feel ?
Deep buttock pain and pain in the posterior thigh.
Pain with squats, lunging,long periods of sitting, running (especially on harder surfaces)
The pain increases with repetitive activities such as long-distance running
Occasional stiffness in the morning may be present or when starting to move after a period of prolonged rest
The onset is mostly gradual, not with acute trauma.
Continued exercises and stretching can cause even more pain
Mechanism of injury
For soccer players the mechanism of injury is the same as for regular hamstring strains with the two typical mechanisms of Sprinting ( High Speed Running) or Stretch Situations.
It seems to be that age plays an important role in this condition as older players (+40) tend to develop this problem and very few cases are in the younger athlete.
Also having a previous Hamstring injury increases substantially the chances of this acute condition to become chronic and highly irritable.
Let’s review the common mechanisms of HS injuries:
1. High Speed Running
During High Speed Running the hamstrings are very active, lengthening ( getting longer) and contracting to absorb the energy from decelerating the weight of the limb and getting the limb ready to stride on the ground again.
This dual demand of contracting and lengthening at the same time is what causes the hamstring excessive “stretch” from its attachment causing the dysfunction.
2. Stretch Situations
The other reason for PHT is a repetitive stretch mechanism.
In this case the hamstrings are required to do hip flexion and knee extension simultaneously.
The most common muscle injured in this type of mechanism is the semimembranosus and its proximal attachment.
What is the best treatment for Proximal Hamstring Tendinopathy
Strengthening of the Hamstrings muscles seem to be the best approach to solver this problem
Acute Phase - Isometric Loading
Isometric exercises in positions that avoid tendon compression is proposed as an effective method of loading the muscle-tendon unit as well as reduce pain in proximal hamstring tendinopathy.
It has been reported that isometric exercises have a pain inhibitory response.
It is recommended that isometric exercises should be repeated several times per day. Symptom severity and irritability are used to determine the dosage. The dosage can be adjusted to shorter/less intense contractions or vice versa, based on the symptoms. Bridges: Hamstring Isometrics and Single Leg bridge Isometric. Start with 5-10 second holds and progress to 45 sec holds Then you can try a single leg hold variance of this exercise Other exercises in this phase could be straight-leg pull downs and Trunk extension
Strengthening Phase - Isotonics with minimal hip flexion
Once pain has settled down, the next steps in the treatment of proximal hamstring tendinopathy are:
to restore hamstring strength
to restore hamstring muscle bulk and capacity
For this condition in particular Heavy Slow Resistance training (HSR) is preferred instead of eccentric exercises. Heavy Slow Resistance training includes eccentric and concentric elements.
With HSR, the aim is to perform a slow fatiguing resisted isotonic exercise. Commence with 15 RM (the maximum load that can be lifted 15 times in a single set) and progress to 8 RM. Perform 3-4 sets every second/other days. Hold contractions for 3 seconds for each phase of the exercise (concentric and eccentric) with a pause of 1-2 seconds in between.
Minimize loaded hip flexion to in the early stages to protect the proximal hamstring insertion against too much compression.
Progress from bilateral workouts to single-leg work to address asymmetrical strength loss. Continue with stage 1 isometric exercises on the "off" days.
This will help with symptom (pain) management, especially if there are still symptoms present.
Other exercises can include Nordic Hamstrings and Prone Leg Curls.
Strengthening Phase - Isotonic exercises in increased hip flexion (70° - 90°)
The aim of rehabilitation in this stage is:
to continue with hamstring muscle strengthening in greater hip flexion
to continue with muscle hypertrophy in greater hip flexion
to continue with functional training in greater hip flexion.
The technique is important and exercises should be performed slow and controlled.
The progression into greater hip flexion often cause pain and irritability and is important to monitor the 24-hour response post exercise with loading tests into hip flexion.
Other exercises can be Single Leg Deadlift , Step-ups and Walking Lunges.
Symptom Modification and Load Management
Training and activity modification are essential in the management of this condition especially with those cases with very irritable symptoms.
Limit pain-producing activities until the pain irritability settles to stable pain. Stable pain is mild (VAS 0 to 3 out of 10) and usually settles within 24 hours of moderate to high tendon load interventions.
One must determine what activities increase the patients' symptoms and for how long?. . Often the player will be able to continue with certain activities such as steady state running within the pain/aggravation guidelines.
Sprinting or quick starts should be avoided initially and only implemented at later stages.
Load modification options:
Swimming and water running are good options
Posture modification may reduce symptoms (e.g. reduce hamstring origin compression by reducing anterior pelvic tilt and hip flexion in standing)
When sitting is symptomatic, shaped cushions are useful to reduce the compression. It allows for more weight bearing on the posterior thigh rather than the ischium
Avoid repeated stretching of the hamstrings in the early, reactive phase
Avoid hip flexion dominant movements such as trunk flexion and repeated lifting in the early, reactive stages
If you want to know more about hamstring injuries see our previous blog on this topic
Proximal Hamstring Tendinopathy is a very debilitation condition that once chronic will affect any type of physical activity causing pain in the buttocks area
This complex condition requires a progressive strengthening program of the Hamstrings and Glute Muscles to restore their capacity.
Solving this condition requires a comprehensive approach to correct all deficits that can be causing the deep glute area pain .
Research shows that a combination of Hip and Knee Strengthening exercises is the best approach to treat PHT
Lionel Pannunzio is a Physical Therapist Certified in Sports Injuries. With more than 20 years of experience helping athletes return to their sports after an injury. He is the Owner of White Bay Sports Physical Therapy and Fitness, conveniently located in the beautiful City of Weston, where he treats Soccer Player, Runners and Athletes of all ages
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