Hamstring Tendinopathy

Hamstring tendinopathy, a condition that causes pain and tenderness in the hamstring tendons, represents a common but often misunderstood musculoskeletal issue. It typically occurs in athletes and individuals engaged in high-intensity activities but isn’t limited to them. This condition, including its more specific form, high hamstring tendinopathy, can significantly impact daily and athletic performance, making understanding its nuances critical.

This article will explore the causes, symptoms, and most effective treatments for hamstring tendinopathy, and provide you with everything you need to know about this condition.

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This e-book by Dr. Chris Centeno examines the knee and its role in the human musculoskeletal system and the body as a whole. The Knee Owner’s Manual provides a series of tests and clearly defined exercises that you can perform on your own to assess and monitor your own knee health. It will allow you to look for trouble spots where your own body may be having difficulty with stability, articulation, symmetry, and neuromuscular function. You’ll be able to see how these deficits in other regions of the body relate to the knee.

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Understanding the Hamstring Muscles

The hamstring muscle is a group of three muscles located at the back of the thigh, functioning together to facilitate various movements of the hip and knee. These muscles are essential for many activities, including walking, running, and jumping. They enable the bending of the knee and the extension of the hip, movements that are fundamental to most lower-body activities. 

The hamstrings consist of three main muscles:

1. Semitendinosus: This muscle originates from the sit bones and inserts into the medial (inside) aspect of the tibia, just below the knee. It is involved in the following functions:
   • knee flexion or bending the knee
   • hip extension or moving the thigh backward
   • internal rotation of the thigh
2. Semimembranosus: Like the semitendinosus muscle, the semimembranosus muscle also originates from the sit bones and inserts into the medial tibia. It performs similar functions: knee flexion, hip extension, and internal rotation of the thigh. Additionally, it helps stabilize the knee joint.
3. Biceps femoris: This muscle has two parts: a long head and a short head. The long head originates from the sit bones, while the short head originates from the femur. Both heads are inserted into the head of the fibula, a small bone located on the lateral side of the tibia. 

What Is Hamstring Tendinopathy?

Tendons are thick pieces of connective tissue that connect muscle to bone, thereby transmitting the force generated by muscle contraction to the skeleton to facilitate movement. Other functions include absorbing impact, protecting muscles, and stabilizing joints. 

Tendinopathy is a broad term referring to a disorder of a tendon, which encompasses conditions involving tendon inflammation, irritation, and degeneration. This condition typically arises from overuse or overload, leading to pain, swelling, and impaired function of the affected tendon. Unlike acute tendon injuries, tendinopathy usually develops over time due to repetitive stress, without a specific onset of injury.

Hamstring tendinopathy is a common medical condition characterized by discomfort and sensitivity around the tendons connecting the hamstring muscles to bones. This condition can manifest at the upper attachment point in the buttocks area or where the tendons insert onto the knee.

Symptoms Related to the Condition

The most common symptoms associated with hamstring tendinopathy include:

Swelling and Pain in the Back of the Kneel

Pain located in the back of the knee is a common symptom of hamstring tendinopathy. It typically worsens with activity and eases with rest.

Tightness in the Back of the Knee

Tightness or stiffness in the back of the knee can also be a sign of hamstring tendinopathy. This tightness may increase with certain activities, such as running or jumping.

Bruising in the Knee Area

Some individuals may experience bruising around the back of the knee or upper thigh, especially if there has been a recent increase in activity or an acute injury.

Fibular Head Pain

In some cases, the biceps femoris tendon may be affected, leading to pain and tenderness around the head of the fibula, a small bone located on the outside of the knee.

Gluteus Medius Pain

The gluteus medius muscle, located on the side of the hip, can also be affected in cases of high hamstring tendinopathy. This may result in pain and discomfort in the buttock area.

Hamstring Pain Behind the Knee

Pain specifically behind the knee, where the tendons connect to the bones, is a hallmark symptom of hamstring tendinopathy. This pain may feel deep and achy and may worsen with certain activities.

Hamstring Pain When Sitting

Sitting for long periods can aggravate hamstring tendinopathy, causing pain or discomfort in the back of the knee. This may make it difficult to sit for extended periods, especially in a hard-backed chair.

Knee Pain at Night

Some individuals may experience increased discomfort and pain in the back of the knee at night, affecting sleep quality.

Knee Swelling

Swelling and tenderness over the back of the knee may also occur with hamstring tendinopathy. This can make it difficult to bend or straighten the knee fully.

Lower Back Pain When Sitting

In cases where the upper attachment of the hamstrings is affected, lower back pain may occur when sitting for extended periods.

Lower Back Pain When Standing

Similarly, standing for long periods may worsen lower back pain associated with hamstring tendinopathy.

Pain Behind the Knee When Walking

Walking or other weight-bearing activities may worsen the pain and discomfort in the back of the knee.

Tight Hamstrings & Calves

Tightness in the hamstring muscles and calves is a common symptom of hamstring tendinopathy. This may restrict movement and make it difficult to perform certain activities.

Tightness in the Knee

Some individuals may experience a feeling of tightness or tension in the knee, making it difficult to fully extend or bend the leg.

Common Causes of Hamstring Tendinopathy

Hamstring tendinopathy typically occurs as a result of repetitive strain and overload on the tendon. This condition often arises due to the tendon being repeatedly subjected to high energy demands, such as during running and jumping activities. When these demands become excessive and sustained without adequate recovery periods the tendon can become irritated, inflamed, and eventually undergo structural changes leading to weakness and pain. A common example is increasing training intensity too quickly or not allowing for sufficient rest.

The most common risk factors for hamstring tendinopathy include:

Overuse and Repetitive Stress

Athletes and other individuals participating in activities involving frequent running, jumping, or sudden starts and stops are at higher risk due to repetitive strain on the hamstring tendons.

Sudden Increase in Activity

Rapidly increasing the intensity, duration, or frequency of physical activities without adequate conditioning can overload the hamstring tendons.

Inadequate Recovery

Insufficient rest and recovery time between intense physical activities can prevent the tendons from healing properly, increasing the risk of tendinopathy.

Poor Flexibility and Muscle Imbalance

Limited flexibility in the hamstrings and an imbalance between the strength of the hamstrings and their opposing muscle groups, such as the quadriceps, can contribute to the development of tendinopathy.

Age

Tendons lose elasticity and become more prone to injury with age, making older adults more susceptible to tendinopathy.

Previous Hamstring Injury

A history of hamstring injuries can predispose an individual to tendinopathy.

Improper Training Techniques

Incorrect form during exercise and sports can put unnecessary stress on the hamstrings, leading to overuse injuries.

Increase in Body Mass Index

An increase in Body Mass Index can elevate the risk of developing hamstring tendinopathy due to the additional stress placed on the tendons and muscles supporting the increased body weight. This added strain can lead to overuse injuries in the hamstrings, making it crucial to manage weight effectively to reduce the likelihood of tendinopathy.

Trauma or Injuries

Hamstring injuries are one of the most common injuries in athletes. The hamstrings are responsible for knee flexion and hip extension, which are essential movements in running. Hamstring injuries can be caused by a variety of factors, such as overuse, sudden overload, increasing mileage or intensity too quickly, prior hamstring injury, poor flexibility, and muscle imbalance.

Examination and Diagnosis

The examination and diagnosis of hamstring tendinopathy typically involve a combination of clinical assessment, patient history, physical examination, and sometimes imaging studies.

Patient History

• The medical practitioner will take a detailed history, including the onset of symptoms, severity, location, aggravating and alleviating factors, prior injuries, prior surgeries, current medications, and current medical history.

Physical Examination

• Palpation: The area around the sit bone and along the course of the hamstring tendon will be palpated to identify tenderness or swelling. 
• Muscle testing: The strength and function of the hamstring muscles will be assessed through various manual muscle testing techniques.
• Range of motion: The range of motion of the hip and knee joints may be evaluated, looking for any limitations or pain with specific movements.
• Functional tests: Functional movements, such as squatting, lunging, or hopping, may be performed to assess pain and dysfunction during dynamic activities.

Imaging Studies

• While not always necessary for diagnosis, imaging studies such as ultrasound or magnetic resonance imaging (MRI) may be ordered if the diagnosis is unclear. At the Centeno-Schultz Clinic, in-office ultrasound examinations are utilized for patients with suspected tendon injuries. Ultrasound is a powerful imaging technique that can evaluate the integrity of a tendon and the stability of a joint. 

Common Treatment Options

The treatment of hamstring tendinopathy typically involves a combination of conservative measures aimed at reducing pain, improving function, and promoting healing of the affected tendon. Here are some common treatment options:

Rest and Activity Modification

Resting the affected leg and avoiding activities that exacerbate symptoms, such as running, jumping, or heavy lifting, can help reduce strain on the hamstring tendon and promote healing. 

Physical Therapy

Physical therapy plays a crucial role in the management of hamstring tendinopathy. A physical therapist can design a tailored exercise program to improve flexibility, strength, and stability of the hamstring muscles and surrounding structures.

Manual Therapy

Techniques such as massage, myofascial release, and joint mobilizations may be used by physical therapists to reduce muscle tightness, improve tissue mobility, and alleviate pain associated with hamstring tendinopathy.

Biomechanical Assessment and Correction

Addressing underlying biomechanical issues, such as gait abnormalities or muscle imbalances, can help alleviate stress on the hamstring tendon and prevent the recurrence of symptoms. Orthotics (shoe inserts) may be recommended to correct foot and ankle alignment.

Steroid Injections

When rest and physical therapy fail to provide significant or sustained benefit, patients are often referred for steroid injections. Steroids are powerful anti-inflammatory agents that can reduce inflammation. Examples include dexamethasone, methylprednisolone, and triamcinolone. While steroids can offer short-term pain relief, they do not address the underlying cause of the tendon injury and can actually cause tendon weakening or rupture. 

NSAIDs

The other day I was evaluating a patient and reviewing the treatment options for their spine condition.  After discussing prior treatments, we got to the topic of medications taken for pain relief. She explained that she mainly utilized anti-inflammatory (NSAID) medications and then she told me to hold much she takes and has been for many years…..she takes close to 2 grams (2000 milligrams) on a daily basis which equated to about 9-10 capsules of medication per day.  I was shocked, considering she was pre-diabetic and with high blood pressure plus the kicker of it is that her PCP (primary care physician) is ok with this…

Read More About NSAIDs

Prolotherapy Injections

It has been successful in the treatment of many disorders including neck, shoulder, knee, and ankle pain. Dr. Centeno recently published an article in The Journal of Prolotherapy in which he discusses the use of x-ray guidance with prolotherapy. This ensures that the injection is in the correct place to maximize clinical results. Dr. Centeno discusses the use of prolotherapy for the treatment of neck, knee, sacroiliac joint, ankle, ischial tuberosity, and shoulder pain. At the Centeno-Schultz Clinic x-ray guided prolotherapy is just one of the therapies utilized in the successful treatment of pain. Regenerative injection therapy (RIT) or prolotherapy…

Read More About Prolotherapy Injections

PRP Injections

PRP is short for platelet-rich plasma, and it is autologous blood with concentrations of platelets above baseline values. The potential benefit of platelet-rich plasma has received considerable interest due to the appeal of a simple, safe, and minimally invasive method of applying growth factors. PRP treatments are a form of regenerative medicine that utilizes the blood healing factors to help the body repair itself by means of injecting PRP into the damaged tissue. In regenerative orthopedics, it is typically used for the treatment of muscle strains, tears, ligament and tendon tears, minor arthritis, and joint instability. There have been more than 30 randomized controlled trials of PRP…

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PRP Knee Injections

PRP stands for Platelet-Rich Plasma. Platelets are blood cells that prevent bleeding. They contain important growth factors that aid in healing. Plasma is the light yellow liquid portion of our blood. So PRP is simply a concentration of a patient’s own platelets that are suspended in plasma and are used to accelerate healing. PRP is NOT stem cell therapy. Regrettably, blood contains few circulating stem cells. Rich sources of stem cells are bone marrow and fat. PRP is rich in growth factors. There are many different types of growth factors with different properties. VEGF is a very important one as it can increase the blood flow to an area.

Read More About PRP Knee Injections

Tenex Procedure

The Tenex Health TX® System is a minimally-invasive, percutaneous procedure using ultrasonic energy to treat pain-generating soft and hard tissue conditions. This treatment is clinically proven to remove tendon pain for over 85% of patients1,2,3,4,5. If conservative approaches such as physical therapy, cortisone injections, medication, and downtime do not provide relief, Tenex may be your next option.Using this technique, we help patients restore musculoskeletal function, may provide quick pain relief, and avoid invasive surgery and dangerous drugs. Tenex may also be effective if you have had a failed surgical procedure. Your doctor will use image-guidance to identify and target the…

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The Regenexx Regenerative Approach to Hamstring Tendinopathy

PRP has gained popularity in the treatment of various musculoskeletal injuries, including hamstring tendinopathy. PRP is derived from the patient’s own blood and contains a concentrated amount of platelets, growth factors, and other bioactive proteins that play a crucial role in tissue healing and regeneration. Here are some of the ways in which PRP is thought to treat hamstring tendinopathies:

Stimulates Tissue Repair

PRP contains high concentrations of platelets, which release growth factors such as platelet-derived growth factor (PDGF), transforming growth factor-beta (TGF-beta), and vascular endothelial growth factor (VEGF). These growth factors play key roles in promoting tissue repair.

Reduces Inflammation

Chronic inflammation is often a contributing factor to tendon degeneration and pain in conditions like hamstring tendinopathy. PRP has anti-inflammatory properties that can help modulate the inflammatory response within the tendon.

Promotes Neovascularization

Adequate blood supply is crucial for tendon healing. PRP therapy promotes neovascularization (the formation of new blood vessels) in the injured tendon. Improved blood flow brings oxygen, nutrients, and immune cells to the site of the injury, accelerating repair.

Less Is More When It Comes to Treating Your Pain

In conclusion, when it comes to treating your pain, the adage “less is more” rings true. While there are various treatment options available for conditions like hamstring tendinopathy, it’s essential to approach regenerative medicine with caution and select interventions that prioritize long-term healing and functionality. Seeking evaluation and guidance from experienced medical professionals is crucial in accurately diagnosing the underlying causes of pain and developing a personalized treatment plan tailored to your specific needs. 

At the Centeno-Schultz Clinic, our board-certified, fellowship-trained physicians are committed to providing comprehensive care focused on addressing the root causes of your symptoms and promoting optimal recovery.

Schedule an in-office or virtual evaluation and learn whether you are a candidate for regenerative treatments. 

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Thoracic Spine Physician and Expert

John Schultz, MD

John R. Schultz M.D. is a national expert and specialist in Interventional Orthopedics and the clinical use of bone marrow concentrate and PRP for orthopedic injuries. He is board certified in Anesthesiology and Pain Medicine and underwent fellowship training. Dr. Schultz has extensive experience with same day as well as culture expanded bone marrow concentrate and sees patients at the CSC Broomfield, Colorado Clinic, as well the Regenexx Clinic in Grand Cayman. Dr. Schultz emphasis is on the evaluation and treatment of thoracic and cervical disc, facet, nerve, and ligament injuries including the non-surgical treatment of Craniocervical instability (CCI).

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