High Hamstring Tendinopathy: A Pain in the Bum

When an athlete tries to remove a shoe pulling back against the other foot, pain in the hamstring denotes a positive ’shoe off’ test. 

Treatment

Langford illustrates a typical progression of conservative management of an athlete with HHT, emphasizing progressive eccentric loading. One challenge in treating these injuries is managing hamstring load in the athlete’s daily activities. Hip flexion places a stretch on the tendon, and thus loads the site. Athlete’s in the acute stage should avoid sitting for long periods of time. Suggest standing at a desk, frequent walk breaks, or reclining chairs to decrease hip flexion. Athletes who receive conservative management follow the typical rehabilitation course of 12 weeks to return to pain free function. Again, education and managing expectations are of the highest priority to ensure safe return to play and avoid repeated injury.

Shockwave therapy, the same treatment initially developed for the treatment of kidney stones, is another tool used to treat HHT. An Italian study published in 2011 but conducted in 2006, found that athletes with HHT who received shockwave therapy fared better than those randomly assigned to receive conservative therapy⁽²⁾. While positive outcomes came from the shockwave branch of the study, a look at the conservative management reveals that the treatment that group received is outdated. Therefore, while the adverse effects of shockwave therapy are minimal, the evidence for its use over conservative management is lacking. Furthermore, in the United States, medical insurance doesn’t typically cover its use for this injury⁽³⁾.

Lastly, athletes may resort to injection therapy to manage either the acute pain, or the chronic nature of HHT. As Langford points out, while initially effective, conservative management using heavy slow resistance training showed more positive results in the long term. Injection therapy is not without risk, as Tracy Ward explores here (see Table 1). Therefore, it should be undertaken judiciously in athletes who simply cannot tolerate movement or manage the pain.

Table 1: Side effects and risks of injection therapy

Note: All invasive procedures carry side effects and risks. However, if the athlete is screened correctly and appropriately selected for the injection then the risks are low. 

SIB Final word

As we close out this series, an overwhelming theme runs through. Tendinopathy, once taken hold, requires time and loading to heal. Other therapies, such as NSAIDs and injections can be deployed to help manage the pain, but they don’t hurry the healing process. All patients fare better when they are educated and know what to expect. Therefore, don’t make false promises or fall into the trap of thinking some magical treatment will accelerate healing. The best way to treat tendinopathy is to avoid tendon strain in the first place by making smart training decisions. However, when it can’t be avoided, progressive loading through eccentric contractions or heavy slow resistance training over a 12 week period is the best strategy to safely return an athlete to their previous level of play, no matter which tendon is injured.

References

1. Br J Hosp Med (Lond). 2018 Jul 2;79(7):389-394.
2. Am J Sports Med 2011;39:146-153.
3. PM R. 2018 May 31. pii: S1934-1482(18)30237-5 [Epub ahead of print]