What is the treatment for proximal hamstring tendinopathy?

Proximal Hamstring Tendinopathy Treatment

Eccentric strengthening exercises are the most effective first-line treatment for proximal hamstring tendinopathy, combined with relative rest and appropriate pain management. 1

Initial Management (0-4 weeks)

First-line Treatments

• Relative rest and activity modification: Reduce activities that aggravate symptoms to prevent further damage and promote healing 1
• Cryotherapy: Apply melting ice water through a wet towel for 10-minute periods to provide acute pain relief 1
• NSAIDs: Effective for short-term pain relief, though they don't affect long-term outcomes 1
  • Ibuprofen (1.2g daily initially, can be increased to 2.4g if needed)
  • Consider topical NSAIDs which may have fewer systemic side effects

Rehabilitation Program

• Eccentric strengthening exercises: Begin with controlled, progressive loading of the hamstring tendon 1, 2
  • Nordic hamstring exercises with gradual progression
  • Single-leg deadlifts with light weight
• Heavy slow resistance training: Includes both concentric and eccentric phases, which has shown positive results in a powerlifter with proximal hamstring tendinopathy 2
  • Begin with 3 sets of 15 repetitions at lighter loads
  • Gradually progress to 4 sets of 6-8 repetitions with heavier loads

Intermediate Management (4-8 weeks)

If symptoms persist after 4 weeks of conservative management:

Advanced Rehabilitation

• Progressive strengthening: Increase load gradually in heavy slow resistance training 2
• Sport-specific exercises: Begin incorporating movement patterns specific to the patient's activities

Adjunctive Therapies

• Shockwave therapy: Very low-level evidence suggests this may be more effective than multi-modal interventions for improving symptoms and physical function 3, 4
• Corticosteroid injections: May provide short-term relief but do not alter long-term outcomes; limit to 2-3 injections with 4-6 weeks between injections 1

Advanced Management (8-12+ weeks)

For persistent symptoms despite appropriate conservative management:

Injection Therapies

• Platelet-rich plasma or autologous whole-blood injections: Very low-level evidence shows no significant difference between these interventions 3

Surgical Intervention

• Consider surgical referral: If symptoms persist despite 3-6 months of well-managed conservative therapy 1, 5
• Surgical options:
  • Semimembranosus tenotomy and sciatic nerve exploration 5
  • Debridement of the conjoint tendon and reinsertion 6
  • Surgery has shown good results in athletes with chronic proximal hamstring tendinopathy unresponsive to conservative management 5

Return to Activity Criteria

• Complete resolution of pain during and after activity
• Full range of motion compared to uninjured side
• Strength symmetry >90% compared to uninjured side
• Successful completion of sport-specific functional tests

Common Pitfalls and Caveats

1. Overlooking load management: Failing to appropriately modify activities that aggravate symptoms can lead to persistent tendinopathy
2. Premature return to activity: Returning to full activity before adequate healing can cause recurrence
3. Relying solely on passive treatments: Active rehabilitation with progressive loading is essential for tendon remodeling
4. Overuse of corticosteroid injections: While providing short-term relief, these may weaken the tendon structure if overused
5. Delayed surgical referral: Waiting too long before considering surgical options in cases that fail to respond to conservative management

Treatment Algorithm

1. Start with relative rest, cryotherapy, and NSAIDs for pain control
2. Implement eccentric strengthening or heavy slow resistance training program
3. If minimal improvement after 4-8 weeks, consider shockwave therapy or injection options
4. For persistent symptoms beyond 3-6 months of appropriate conservative management, consider surgical consultation