What is the treatment for biceps femoris (hamstring) tendinitis?

Treatment of Biceps Femoris Tendinitis

Begin with 3-6 months of conservative management consisting of relative rest, eccentric strengthening exercises, NSAIDs, and cryotherapy before considering any invasive interventions. 1

Initial Conservative Treatment (First-Line, 3-6 Months)

Relative Rest and Activity Modification

• Reduce repetitive loading activities that stress the biceps femoris tendon while maintaining some activity to prevent muscle atrophy 1
• Avoid complete immobilization, which leads to muscular atrophy and deconditioning 2, 3
• For athletes, modify training techniques to minimize repetitive strain on the hamstring tendons 2

Eccentric Strengthening Exercises

• Eccentric strengthening is the cornerstone of treatment and can reverse degenerative changes in the tendon 1, 2
• This is the most effective long-term intervention for tendinopathy 1

Pain Management

• NSAIDs (oral or topical) provide short-term pain relief but do not affect long-term outcomes 1
• Topical NSAIDs are preferable due to fewer systemic side effects, particularly elimination of gastrointestinal hemorrhage risk 2, 3
• For oral NSAIDs, naproxen 500 mg twice daily is effective for acute tendinitis and bursitis 4
• Cryotherapy through a wet towel for 10-minute periods provides effective acute pain relief 3, 5

Expected Outcomes

• Approximately 80% of patients with overuse tendinopathies recover completely within 3-6 months with appropriate conservative treatment 2, 3

Secondary Treatment Options (If Conservative Measures Partially Effective)

Corticosteroid Injections

• Local corticosteroid injections may be more effective than oral NSAIDs for pain relief in the acute phase, but do not improve long-term outcomes 1, 2
• Critical pitfall: Never inject directly into the tendon substance, as this inhibits healing, reduces tensile strength, and may predispose to rupture 3, 5
• Inject into the peritendinous space only 3
• Avoid multiple injections as they may weaken tendon structure despite short-term symptom relief 3, 5

Advanced Conservative Options

• Extracorporeal shock wave therapy (ESWT) appears safe and effective for chronic tendinopathies, though costly 1, 2
• Therapeutic ultrasonography has uncertain benefit but may decrease pain and increase collagen synthesis 1, 2
• Deep friction massage may provide additional benefit 3

Special Consideration: Calcific Tendinitis

• If imaging reveals calcium deposits within the biceps femoris tendon, ultrasound-guided barbotage of calcium deposits with peritendinous corticosteroid injection can provide rapid symptom relief 6, 7
• This specific variant responds well to barbotage when conservative measures fail 7

Surgical Management (Last Resort)

Surgery is justified only if pain persists despite 3-6 months of well-managed conservative treatment 1, 2

Surgical Techniques

• Excision of abnormal tendinous tissue and longitudinal tenotomies to release areas of scarring and fibrosis 2, 3
• For accessory biceps femoris bands causing snapping and pain, tenodesis of the accessory band to the direct insertion may be required 8

Diagnostic Considerations

Physical Examination Findings

• Well-localized tenderness over the biceps femoris tendon that reproduces activity-related pain 1
• Pain with resisted knee flexion or hip extension 9
• Insidious onset of load-related pain coinciding with increased activity 1
• Pain described as "sharp" or "stabbing" 1

Imaging

• Plain radiography may reveal calcifications but generally does not visualize soft tissue changes of tendinopathy 1, 6
• Ultrasonography is cost-effective for visualizing calcium deposits and tendon pathology 6, 7
• MRI is reserved for unclear diagnoses, recalcitrant pain despite adequate conservative management, or preoperative evaluation 1

Critical Pitfalls to Avoid

• Never inject corticosteroids directly into the tendon substance 3, 5
• Do not proceed to surgery without an adequate 3-6 month trial of conservative treatment 2, 3
• Avoid complete immobilization for prolonged periods 2, 3
• If multiple tendons are symptomatic, evaluate for underlying rheumatic disease 1, 3
• Do not rely on NSAIDs alone for long-term management—they provide only short-term pain relief 1