What is the treatment for proximal hamstring tendinopathy?

Treatment for Proximal Hamstring Tendinopathy

The most effective first-line treatment for proximal hamstring tendinopathy consists of relative rest, icing, and eccentric strengthening exercises, with approximately 80% of patients fully recovering within three to six months using these conservative measures. 1

Conservative Management Algorithm

First-Line Interventions:

• Relative Rest and Activity Modification

  • Reduce activities that aggravate symptoms
  • Avoid prolonged sitting when possible
  • No clear recommendations exist for the duration of rest 1

• Cryotherapy

  • Apply melting ice water through a wet towel for 10-minute periods
  • Provides acute pain relief (Evidence rating: B) 1

• Eccentric Strengthening Exercises

  • Most beneficial for tendinopathies (Evidence rating: B)
  • May reverse degenerative changes in the tendon
  • Focus on controlled lengthening of hamstring muscles 1, 2
  • Incorporate lumbopelvic stabilization exercises 2

Second-Line Interventions:

• Pain Management

  • NSAIDs (oral) for short-term pain relief only
    • No effect on long-term outcomes (Evidence rating: B) 1
  • Topical NSAIDs may provide pain relief with fewer systemic side effects 1

• Physical Therapy Adjuncts

  • Trigger point dry needling may help decrease pain and improve motion 2
  • Deep transverse friction massage to reduce pain

Third-Line Interventions:

• Corticosteroid Injections

  • May be more effective than NSAIDs for acute pain relief
  • Do not alter long-term outcomes (Evidence rating: B)
  • Use with caution as they may inhibit healing and reduce tendon tensile strength 1

• Extracorporeal Shock Wave Therapy (ESWT)

  • Very low-level evidence suggests ESWT may be more effective than multi-modal intervention for improving symptoms and physical function 3, 4
  • One randomized controlled trial showed 85% of patients achieved at least 50% reduction in pain at 3 months 4

• Other Injection Therapies

  • Platelet-rich plasma (PRP) and autologous whole-blood injections have been studied
  • Very low-level evidence of no significant difference between these interventions 3

Surgical Management

• Indications for Surgery:

  • Failure of conservative treatment after 3-6 months 1, 5
  • Persistent pain and functional limitations 5

• Surgical Techniques:

  • Excision of abnormal tendon tissue
  • Longitudinal tenotomies to release areas of scarring and fibrosis 1
  • Semimembranosus tenotomy and sciatic nerve exploration 5
  • Debridement and reinsertion of the conjoint tendon 6

• Surgical Outcomes:

  • Very low-quality evidence shows large reduction in symptoms and improved physical function in the long term 3
  • One case series (n=103) reported excellent or good results in 92 of 103 cases 5
  • Average return to pre-injury sporting level: 5 months (range 2-12 months) 5

Important Considerations and Pitfalls

• Diagnostic Challenges:

  • Proximal hamstring tendinopathy can mimic other conditions like piriformis syndrome or lumbar radiculopathy
  • MRI is helpful to confirm diagnosis when symptoms persist 3

• Treatment Pitfalls:

  • Overreliance on passive treatments without addressing the underlying tendon pathology
  • Premature return to aggravating activities before adequate healing
  • Delayed progression from conservative to surgical management when appropriate can lead to prolonged disability 1
  • Overuse of corticosteroid injections may weaken tendon structure and predispose to rupture

• Rehabilitation Focus:

  • Progressive loading is essential for tendon healing and remodeling
  • Address any biomechanical factors contributing to the condition
  • Gradual return to sport with appropriate technique modification

Most patients with proximal hamstring tendinopathy respond well to conservative treatment within 3-6 months. For those who fail to improve, surgical intervention has shown good results with appropriate patient selection.