What is the recommended treatment for hamstring tendinitis?

Treatment for Hamstring Tendinitis

Begin with relative rest, ice therapy, and eccentric strengthening exercises as the foundation of treatment, with NSAIDs for acute pain relief only—approximately 80% of patients fully recover within 3-6 months using this conservative approach alone. 1

Understanding the Pathology

Recognize that what is commonly called "hamstring tendinitis" is actually degenerative tendinopathy (tendinosis) rather than acute inflammation, which fundamentally changes your treatment approach. 2, 1 The underlying pathology involves hypoxic tendon degeneration with hypercellularity and neovascular proliferation, not inflammatory cells. 3 This explains why anti-inflammatory treatments alone often prove insufficient for long-term recovery. 4

First-Line Conservative Management

Relative Rest (Not Complete Immobilization)

• Reduce activity to decrease repetitive loading while avoiding complete immobilization, which causes rapid muscle atrophy, loss of strength, and loss of extensibility. 1, 5
• Use pain as your guide—continue activities that don't aggravate symptoms while avoiding those that worsen pain. 1
• Complete immobilization should be avoided as it leads to muscle deconditioning and delays functional recovery. 4

Ice Therapy

• Apply ice through a wet towel for 10-minute periods to provide effective short-term pain relief by reducing tissue metabolism. 1

Eccentric Strengthening Exercises

• Eccentric exercises are the cornerstone of rehabilitation and should be initiated once acute pain subsides. 1
• These exercises can reverse degenerative tendon changes and are essential for achieving the 80% recovery rate seen with conservative management. 3, 4
• Do not permit return to full activity until complete rehabilitation is achieved, including full return of muscle strength, endurance, flexibility, coordination, and athletic agility. 6

NSAIDs for Acute Pain

• 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

Expected Timeline

• The natural history shows gradually increasing load-related localized pain coinciding with increased activity. 1
• Approximately 80% of patients fully recover within 3-6 months with appropriate conservative management. 2, 3, 1
• Complete normalization of tendon strength often exceeds this 3-6 month period. 3

Second-Line Treatment Options (Use With Caution)

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
• Avoid multiple corticosteroid injections, as they may weaken tendon structure despite providing short-term symptom relief. 4, 1

Extracorporeal Shock Wave Therapy (ESWT)

• ESWT appears safe and effective for chronic hamstring tendinopathy but is expensive. 3, 1
• Consider this as a noninvasive option for chronic cases before proceeding to surgery. 3

Platelet-Rich Plasma (PRP)

• PRP injections are currently being investigated as an adjunct therapy for hamstring injuries. 7, 8

Other Modalities of Uncertain Benefit

• Therapeutic ultrasonography, corticosteroid iontophoresis, and phonophoresis are of uncertain benefit. 1

Surgical Management

Reserve surgery only for carefully selected patients who have failed 3-6 months of well-managed conservative therapy. 1, 9

Surgical Indications

• Complete proximal avulsions involving 3 tendons. 7, 8
• Partial avulsions with at least 2 tendons injured with >2 cm of retraction in young, active patients. 7, 8
• Chronic tendinosis that has not improved with 6 months of nonoperative management. 7, 8

Surgical Outcomes

• Surgery (semimembranosus tenotomy and exploration of the sciatic nerve) is effective for proximal hamstring tendinopathy, with excellent or good results in 89% of cases. 9
• After surgery, 89% of patients were able to return to the same level of sporting activity, taking a mean of 5 months. 9

Critical Pitfalls to Avoid

• Do not completely immobilize the hamstring for extended periods—this causes rapid muscle atrophy and loss of strength and extensibility. 1, 5
• Do not proceed to surgery without an adequate 3-6 month trial of conservative treatment. 1, 9
• Avoid multiple corticosteroid injections despite short-term relief. 4, 1
• If multiple tendons are symptomatic simultaneously, evaluate for underlying rheumatic disease before attributing symptoms solely to overuse. 4, 1
• Do not allow return to athletic competition until full rehabilitation is achieved—failure to achieve full rehabilitation predisposes to recurrent injury. 6

Diagnostic Considerations

• Most patients presenting to primary care have chronic symptoms suggesting degenerative tendinopathy ("tendinosus") rather than acute inflammation. 1
• MRI remains the gold standard for diagnosis and may help guide treatment decisions. 7
• Plain radiography is usually unable to demonstrate soft-tissue changes but may reveal bony abnormalities. 1