What is the best treatment approach for a patient with hamstring tendinitis?

Treatment of Hamstring Tendinitis

Begin with relative rest, ice therapy, and eccentric strengthening exercises as the foundation of treatment, with NSAIDs for acute pain relief; reserve surgery only for patients who fail 3-6 months of conservative management. 1

Initial Conservative Management (First-Line Treatment)

Activity Modification

• Reduce activity to decrease repetitive loading of the damaged hamstring tendon while avoiding complete immobilization, which leads to muscle atrophy and deconditioning 1
• In athletes, modify technique to minimize repetitive eccentric loading during running and sprinting activities 2
• Pain should guide activity levels—continue activities that don't aggravate symptoms while avoiding those that worsen pain 1

Pain Management

• Topical or oral NSAIDs are effective for acute pain relief, though they cannot be recommended over other analgesics and do not affect long-term outcomes 1
• Topical NSAIDs provide equivalent pain relief with fewer systemic side effects compared to oral formulations 1
• Ice therapy applied through a wet towel for 10-minute periods provides effective short-term pain relief by reducing tissue metabolism 1

Rehabilitation Core

• Eccentric strengthening exercises are the cornerstone of rehabilitation and should be initiated once acute pain subsides 1
• Stretching exercises should be incorporated alongside strengthening to restore flexibility 3, 4
• Physical therapy with functional exercises has been emphasized, though no consensus exists on optimal rehabilitation protocols 3, 2

Expected Timeline and Natural History

• Approximately 80% of patients with overuse tendinopathies fully recover within 3-6 months with appropriate conservative management 1
• The condition typically presents with insidious onset of load-related localized pain coinciding with increased activity 1
• Pain may initially subside after warm-up but gradually increases in intensity and duration, potentially becoming present at rest in later stages 1

Second-Line Treatment Options (For Persistent Symptoms)

Corticosteroid Injections

• Use corticosteroids with extreme caution—while they provide short-term pain relief, they do not improve long-term outcomes and may have deleterious effects on tendon healing 1
• Never inject directly into the tendon substance, as this inhibits healing, reduces tensile strength, and may predispose to rupture 1

Advanced Modalities

• Extracorporeal shock wave therapy (ESWT) appears safe and effective for chronic hamstring tendinopathy but is expensive 1, 5
• In professional athletes with chronic proximal hamstring tendinopathy, ESWT (2500 impulses at 0.18 mJ/mm² for 4 weeks) achieved 85% pain reduction ≥50% at 3 months versus 10% with traditional conservative treatment 5
• Platelet-rich plasma injections are currently being investigated but lack definitive evidence 2, 6
• Therapeutic ultrasonography, corticosteroid iontophoresis, and phonophoresis are of uncertain benefit 1

Surgical Management

Indications

• Surgery should be reserved for carefully selected patients who have failed 3-6 months of conservative therapy 1
• For proximal hamstring injuries specifically, traditional surgical indications include: 2-tendon injuries with >2 cm retraction, 3-tendon injuries, or failure to improve with 6 months of nonoperative management 6
• Complete ruptures with loss of function require operative treatment 4

Surgical Approach

• Surgical techniques typically include debridement of abnormal tendon tissue and reattachment to the ischial tuberosity for proximal injuries 2, 6
• Acute surgical treatment of proximal hamstring injuries tends to have favorable outcomes 6

Critical Pitfalls to Avoid

• Do not completely immobilize the hamstring for extended periods—this causes rapid muscle atrophy, loss of strength and extensibility 1, 4
• Avoid multiple corticosteroid injections, as they may weaken tendon structure despite providing short-term symptom relief 1
• Do not proceed to surgery without an adequate 3-6 month trial of well-managed conservative treatment 1
• If multiple tendons are symptomatic, evaluate for underlying rheumatic disease before attributing symptoms solely to overuse 1
• Distinguish hamstring tendinitis from acute muscle strains or avulsion injuries at the ischial tuberosity, which may require different management approaches 3, 4

Diagnostic Considerations

• Most patients presenting to primary care have chronic symptoms suggesting degenerative tendinopathy ("tendinosus") rather than acute inflammation, despite the common misnomer "tendinitis" 1
• MRI remains the gold standard for diagnosis when clinical examination is unclear or to assess severity and guide treatment decisions 2, 6
• Plain radiography is usually unable to demonstrate soft-tissue changes but may reveal bony abnormalities 1