What is the most appropriate initial management for proximal hamstring tendinopathy?

Initial Management of Proximal Hamstring Tendinopathy

Begin with a structured conservative program combining relative rest, eccentric strengthening exercises, and consider extracorporeal shockwave therapy as a first-line intervention, as this multimodal approach achieves superior outcomes compared to traditional conservative treatment alone. 1, 2

Activity Modification and Load Management

• Implement relative rest by reducing activities that impose repetitive hip flexion and loading at the ischial tuberosity, particularly running, jumping, and prolonged sitting (>30 minutes), while avoiding complete immobilization which accelerates muscle atrophy 3, 4
• For athletes, adjust training technique to minimize repetitive stress on the proximal hamstring insertion 3
• Expect a 3-6 month recovery timeline, with approximately 80% of patients achieving full functional recovery with appropriate conservative management 5, 3

Exercise-Based Rehabilitation Protocol

Eccentric strengthening exercises are the cornerstone of treatment and should be initiated early, as they reverse degenerative tendon changes and improve strength. 3, 6

• Prescribe heavy slow resistance training (HSR) incorporating both concentric and eccentric phases, which has demonstrated superior outcomes in tendinopathy management compared to eccentric-only protocols 4
• Progress hamstring-specific loading exercises at combined hip flexion angles of 110 degrees with knee flexion between 45-90 degrees, as this positioning optimally loads the proximal hamstring tendon 1
• Continue the exercise program for at least 12 weeks, with meaningful pain reduction typically occurring within 4 weeks 4
• Include lumbopelvic stabilization exercises as part of the comprehensive rehabilitation program 1

Pharmacologic Pain Management

• Use oral NSAIDs for short-term symptom relief (they provide analgesia but do not modify the underlying degenerative process) 3, 6
• Prefer topical NSAIDs for localized pain to achieve comparable analgesia with fewer systemic adverse effects 5, 3
• Offer paracetamol (up to 4 g/day) as first-line oral analgesia due to its favorable safety profile 3
• Apply ice (wet towel) for 10-minute intervals immediately after pain-provoking activities for acute pain relief 3, 6

Adjunctive Physical Therapy Modalities

Extracorporeal shockwave therapy (ESWT) demonstrates large effect sizes for symptom reduction and functional improvement, with very low-level evidence showing superiority over multimodal intervention alone. 7, 2

• Administer ESWT at 2500 impulses per session at 0.18 mJ/mm² energy flux density without anesthesia, for 4 sessions over 4 weeks 2
• In professional athletes with chronic proximal hamstring tendinopathy, 85% achieved ≥50% pain reduction at 3 months with ESWT compared to 10% with traditional conservative treatment 2
• Consider therapeutic ultrasound to decrease pain and increase collagen synthesis, though evidence for consistent benefit is weak 5, 6
• Apply deep transverse friction massage to reduce pain 3

Critical Pitfalls to Avoid

• Do not completely immobilize the hip, as this accelerates atrophy and deconditioning 3
• Avoid mislabeling this condition as "tendinitis" when the underlying pathology is degenerative tendinopathy (tendinosis), as this leads to inappropriate treatment choices 5
• Do not rely solely on NSAIDs or corticosteroid injections, as they address only symptoms and not the degenerative pathology; corticosteroids may inhibit healing and reduce tendon strength 3, 6
• Do not start with overly aggressive exercises, as this worsens symptoms; progress loading gradually 6
• Do not allow premature return to full activity before adequate healing (minimum 3-6 months of conservative therapy) 3, 6

When to Consider Advanced Interventions

• Reserve ultrasound-guided platelet-rich plasma or autologous whole-blood injections for cases not responding to initial conservative management, though very low-level evidence shows no difference between these interventions 7
• Refer for surgical consultation only if pain persists despite well-managed conservative treatment for 3-6 months, as surgery involves excision of abnormal tendon tissue and longitudinal tenotomies 6, 7
• Surgical intervention shows large reductions in symptoms and improved physical function in the long-term for carefully selected patients who fail conservative management 7