Tuesday, August 23, 2016

High Hamstring Tendinopathy

High Hamstring Strain and High Hamstring Tendinopathy

Fig 1: Common mechanism of
hamstring injury
High hamstring strain and/or pain at the attachment of the hamstrings (referred to as high hamstring tendinopathy or proximal hamstring tendinopathy) is a common complaint among runners and athletes who are involved in kicking sports such as soccer. The pain is experienced at the region of the sit bones (the ischial tuberosity) and is aggravated with sitting and with activities such as running and kicking. The pain can be sharp, aching, and sore, and it can be described as a pulling sensation. This injury can be very slow to heal and has a high frequency of recurrence.

The hamstrings frequently become injured in their eccentric phase of contraction. What this means is that in activities such as kicking a soccer ball or football, or in the leg swing during running, the hamstrings are lengthening (and the quadriceps are contracting and shortening). Although the hamstrings are lengthening, they fire to slow down or decelerate the motion (Fig.1).

Understanding this mechanism of injury is crucial for Sports Medicine Acupuncturists® such as myself, as this informs clinical inquiry. Are the quadriceps and other hip flexors short and overactive placing the hamstrings in a chronically taut and lengthened position (Fig. 2)? This would need to be addressed to allow adequate healing. Or, are the hamstrings chronically in a shortened position? Both of these situations could be an underlying cause of hamstring strain recurrence and in both situations the patient would complain of 'tight' hamstrings. In the first instance these 'tight' hamstrings are pulled taut like a rubber band overstretched (a very common occurrence), while in the second they are in a short and tight positions. However, treatment strategies for these two instances would be very different.

Fig. 2: Schematic illustrating hamstrings being pulled in a chronically overlengthened position. Patients would complain of chronically 'tight' hamstrings in this case as they are chronically pulled taut. 

Fig. 3: Modified from Netter's
Atlas of Human Anatomy
When patients complain of this pain, it is also important to properly assess which structure is actually injured. While many patients come in to clinic complaining of high hamstring strain, two other structures frequently mimic this pain. The lower fibers of the gluteus maximus overlie the hamstrings at the region where high hamstring strain occurs. When this muscle is the culprit, there is a palpable taut band that can be felt in these fibers from about the region of the coccyx to the attachment of the hamstrings. Also, the adductor magnus, the most posterior muscle in the adductor group which is on the medial thigh, attaches very close to the hamstrings and pain associated with this muscle can mimic high hamstring strain (Fig. 3). Both of these muscles create a slightly different 'flavor' of pain and can have characteristic signs and symptoms reported by the patient; this allows an astute clinician to find the fixed site of pain and treat it properly for the quickest healing time.

Besides these sources of pain, referred pain is also a possibility and needs to be considered. Referred pain may come from the lumbar spine, from the sacroiliac joint, or from trigger points in the gluteal muscles, the low back, or even the lower portion of the hamstrings. The clinician must be thorough during evaluation and patients should make sure that their practitioner, whether an MD, acupuncture physician, physical therapist, or massage therapist, has the understanding and training to properly assess and evaluate the condition. Proper assessment of all the factors leads to proper treatment. Proper treatment leads to faster and more profound healing.

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