The proximal hamstring can present a challenging area to treat once injured. Injuries can either be acute or chronic in nature with various anatomical considerations.
The rehabilitation and medical management of these cases also needs careful thought.
In this case we also demonstrate how the use of Force Plate Testing can guide patients through their rehabilitation journey.
Clinical History
- A 23-year female presents with a sudden “pull” in the left gluteal area during a weight training session doing a deadlift. She was unable to continue training and went home to rest and ice the area.
- For the first few days post injury she walked with a mild limp due to pain. There was no bruising in the gluteal area.
- She found it difficult to sit on the left sit bone at work over the next few weeks. Driving is very uncomfortable even for short periods of time.
- She does not have any pain when she sleeps.
- She has referral pain down the back of the left leg and into the calf, along with some pins and needles in the foot.
- She has tried physiotherapy, but some exercises seem to flare the symptoms.
- She presented to my clinic 6 weeks post injury with ongoing symptoms.
Past Medical History
- Nil of note
Drug History
- Nil of note
Exercise History
Strength trains 3-4 times a week. Enjoys weightlifting and can back squat 70kg and deadlift 100kg.
Clinical Examination
- Gait: Very mildly reduce hip extension on swing phase of left leg.
- Dominance: Patient is left leg dominant.
- Visual Inspection: Normal appearance of the posterior thigh, with no visible bruising, swelling, or muscle atrophy.
- Range of Motion: Deep squat produces pain in left buttock as does stiff leg RDL testing. Full, pain-free knee range with unrestricted hip motion including resisted flexion, internal and external rotation (FADIR, FABER). Resisted prone knee pain also reproduces awareness in the gluteal area.
- Strength Testing: Pain and weakness on long lever bridging on the left hamstring compared to the right.
- Palpation Findings: Notable tenderness in the left ischiogluteal area and proximal hamstring. No tenderness or referred pain on firm PA translation of the lumbar spine processes. No palpation over the deep gluteal muscles.
- Neurological Exam: No myotome weakness or loss of sensation in dermatomes. Slump test mildly positive down left leg.
Bedside Diagnostic Ultrasound
- There is no abnormality of the left semimembranosus, semitendinosus or bicep femoris muscle bellies.
- There is fluid in the ischiogluteal bursa and thickened proximal hamstring tendon, indicating proximal hamstring tendinitis.
Differential diagnosis and clinical reasoning
- Proximal hamstring tendon injury
This injury is a result of an acute mechanism from a heavy deadlift episode. A “pull” or “tweak” in the deep gluteal area is very common symptom for patients with this injury. There is usually not any bruising unless a very significant tear/avulsion. Pain around the sit bone whilst driving for example is also very common.
- Deep gluteal muscle injury.
The deep gluteal muscles can also suffer from sprain or injury in heavy lifting. This can These include the short rotators of the hip and piriformis. However, on clinical assessment, hip testing did not elicit any discomfort which makes this unlikely.
- Lumbar spine nerve root injury
It is very common for sciatica to present as deep gluteal and/or hamstring pain. Patients may also experience a sharp pain in the gluteal area fitting with the history in this case. However, clinical assessment reveals no tenderness or referred pain on firm PA translation of the lumbar spine processes, making spinal injury unlikely. The pins and needles down the leg may well be secondary sciatic neural tension from hamstring tension which also a common phenomenon.
- Hip sprain and/or labral injury
Hip joint pathology must always be considered in any pelvic pain scenario. This patient may have suffered a hip labral injury whilst performing a deadlift. Confusingly, hip pain can be referred in an anterior, posterior, lateral, medial and distal direction making it tricky to diagnose. Hip joint inflammation does however tend to be sensitive to SCOUR testing of the joint and is unlikely to be pain free on testing if significant capsular sprain or labral pathology.
An MRI scan was recommended for further investigation.
Diagnostic Imaging
MRI
Image 1 (axial view) and image 2 (sagittal view) of the left proximal hamstring shows high signal throughout all components of the proximal hamstring including semimembranosus and the conjoint tendon (joint Semitendinosus and Bicep Femoris tendon complex). There is also a florid reactive ischiogluteal bursitis.
Diagnosis: Proximal hamstring insertion tendon injury with resulting ischiogluteal bursitis.
Anatomy and discussion
The proximal hamstring insertion is made up of the semimembranosus and the conjoint (Semitendinosus and Bicep Femoris tendon) complex. Each or all of these components can be subject to injury. Extreme hip flexion injuries (e.g. doing the splits) or being pushed in to lumbar flexion on a fixed standing leg (e.g. rugby tackle) and cause a partial or complete avulsion of the hamstring tendon which being a higher-grade injury may need surgical attention.
The ischiogluteal bursa is one of many pelvic bursae. It completely surrounds the proximal hamstring tendon attached and is therefore reactive to it becoming injured.
In the case presentation, the acute nature of the injury in the history makes it likely that there was some proximal hamstring fibre disruption at is attachment, albeit very low grade. However, 6 weeks on, it is more likely that the resultant inflammation and bursitis is causing most of the patients’ symptoms, particularly the inability to sit on the ischium.
Management and rehabilitation of a proximal hamstring injury
Rehabilitation goals
- The key to rehabilitation high hamstring injury is by starting with non-compressive exercises that will strengthen the proximal tendon insertion. Advising the patient to buy a hamstring cushion to offload the ischium when sitting is also advisable (standing desk is obviously preferrable).
- With such a florid ischiogluteal bursitis it is likely that any exercises that “compress” the proximal hamstring (e.g., deep squat, lunges, end range RDLs) will flare the area. This is likely to have been why the patient experienced flares of pain whilst doing the rehabilitation exercises given by the physiotherapist.
- Bridge Isometric bridge holds, remove all dynamic “friction” of the hamstring tendon and are less likely to flare the ischiogluteal bursa.
- Long – Lever Bridges as an exercise have less gluteal involvement than Short – Lever and therefore are much more effective in targeting the proximal hamstring itself.
- Once the patient had tolerated long lever isometric holds, she was progressed to more dynamic hamstring eccentric and then finally concentric training in greater angles of hip flexion.
In addition to the rehabilitation strategy highlight above, additional medical therapies can be offered with the aim of calming inflammation, improving symptoms and expediting tissue healing.
Focal Shockwave Therapy treatment
Focal ESWT was used very effectively in this case to stimulate healing in the proximal hamstring tendon. The inflamed tendon was marked and depth set via ultrasound to deliver accurate placement of the shockwaves. The patient required 7 sessions, 2 weeks apart, with care to organise her rehabilitation plan around treatments.
Corticosteroid injections
Steroid injections should not be injected into tendon substance (due to an increased risk of subsequent tendon injury). However, targeting the ischiogluteal bursa with ultrasound guidance can be very effective for calming symptoms and reduction pain inhibition. This can also hugely improve the efficacy of any rehabilitation plan. PUT
Image 3 below shows USGI of the ishciogluteal bursa. The needle tip is accurately place in the bursa itself, avoiding injection steroid into the tendon.
Image 3
Platelet rich Plasma injections
The aim of these injections is to aid healing of the tendinopathic/injured proximal tendon. Depending on imaging findings, the plasma is usually injected directly into the most inflamed/damaged part of the tendon to aid healing. We recommend a course of 3 injections 1-2 months apart. PRP injections can initially flare the injected site and make symptoms worse, so the patient needs to be counselled properly and the rehabilitation plan worked accordingly.
Surgical intervention
Surgery is rarely required to treat proximal hamstring tendon issues. Hamstring avulsion from the ischium is usually a high impact force injury with high levels of disability and requires surgical consideration in young fit and active people. Sometimes, chronic proximal hamstring issues that are not responding to rehabilitation or medical therapies may be considered.
Force Plate Testing for Hamstring Strength
Force plate testing (in additional to handheld dynamometry testing) can be very useful in highlighting certain muscle group discrepancies. Hamstring concentric and eccentric power on the left side was more than 40% below the uninjured side on initial testing. This is a significant drop in hamstring strength, most likely from pain inhibition rather than disruption of anatomical structures. Furthermore, in this patient we would expect to see a stronger left hamstring as a baseline due to her left leg dominance.
After 8 weeks for rehabilitation and medical treatment, the patients left hamstring power return to 10% stronger than the right side. Once this had been achieved, the patient had the final sign off to go back to heavier compound lifting in the gym.
The key force plate testing modalities that were used in this case are shown below with the description of how they are routinely conducted.
Hamstring isometric bridge
Allows assessment of either maximal hip extension force or rate of force assessment. It can be performed either double or single leg. The patient lies with the feet on the Forceplates and their shoulders on a 15cm box. A loaded bar (greater than the patient is capable of moving) is placed across their hips. They are then asked to push upwards as hard as possible over two seconds if testing for maximal force. If testing for rapid force assessment, they perform five one-second efforts with ten seconds rest between.
Isometric mid-thigh pull
Used to assess overall strength and force production, including rate of force development and maximal strength. Patients stand on the ForcePlates behind a barbell locked in position in a rack at the height of their mid-thighs. They are then asked to pull upwards as hard and as fast as possible, holding the contraction for at least two seconds.
Squat assessment
Used to assess performance through Force: Velocity profiling, and to assess for squat asymmetry. Patients will be asked to perform a body weight squat with their chest up, knees in line with toes and pushing through the heels.
Counter movement jump
Can be used for assessment of power, fatigue, and monitoring rehabilitation progress with concentric and eccentric measures. Patients stand on the Force plates in a normal standing posture, with their hands on their hips. They then bend down into a partial squat and jump up as high as possible before landing softly.
Key Learning Points
- Proximal hamstring injuries are common and can present with long standing symptoms.
- Sciatica and hip related pain are 2 key differentials to exclude.
- MRI is the most sensitive diagnostic tool when investigation the proximal hamstring tendon. It is important to make sure that the ischium and proximal hamstring insertion is fully imaged and not missed.
- Avoid compression on the ischium and hamstring origin is one of the key components in the initial stages of rehab. Exercises need to be planned careful to avoid aggravating the area.
- Long lever isometric bridges are a safe and effective way of loading the proximal hamstring.
- Focal Shockwave is a very effective non-invasive tool that can aid rehabilitation. Given the depth of the proximal hamstring tendon, we recommend depth setting and anatomical marking via ultrasound prior to treatment. Radial shockwave is much less effective in treating deep hamstring tendons and we suggest avoiding this.
- Injection therapies can be very useful depending on the case presentation. All ischiogluteal injections should be done under ultrasound guidance by an experience clinician given the proximity to neurovascular structures such as the sciatic nerve.
- Force plate testing give invaluable data highlighting strength deficits in particular muscle groups and as an objective measure of strength. This helps patients buy into strength training as a concept and creating a positive patient experience and outlook, even if clinical symptoms such as pain persists for a while.
