Start Spring Right- Give Your Hamstrings a Little Love...

I had a few of you ask about hamstring tendon injuries. That nagging feeling of a high (proximal) hamstring injury is hard to miss. Running more than a snail’s pace without pain seems impossible. It is fairly common in endurance athletes and can be extremely difficult and frustrating to treat and may become a chronic problem.

The hamstrings start at the ischial tuberosity (that bony protruberance you can feel if you sit on your hands) and run down to the top of the tibia. The area of origin (near the ischial tuberosity) is a common place to have injury. The hamstrings aid in knee flexion and hip extension. Runners use them especially when increasing speed or running uphill. Often runners will feel similar pain when stretching the hamstrings. Other pain generators that can mimic this pain in the deep buttock and upper thigh include piriformis pain, sciatic pain, low back injury and pelvic stress fractures.

Hamstring injuries are often diagnosed in clinic by a series of range of motion and strength testing. Physicians competent with diagnostic ultrasound can look at the tendon right in the office and evaluate for any tears or inflammation. An MRI can also be done, but is about 10 times as costly as ultrasound. In studies, ultrasound is as accurate as MRI and much easier, as it is done in the clinic.

Treatment of this issue, like most sports injuries, starts with conservative measures. Relative rest, icing and physical therapy are mainstay of first line treatment. Gait analysis may be used to asses extra strain placed on the tendons. Strength training in rehabilitation consists of a series of exercises starting with concentric exercises (strengthening while shortening the muscle) moving to eccentric exercises (strengthening while lengthening the muscle). Stabilizing the core is also essential in hamstring rehabilitation. The hamstrings have a poor blood supply and if a chronic process sets in the tendons undergo degeneration rather than inflammation. Tendon fibers can lose their solid structure and fray or tear. Again, this can be seen on ultrasound.

If the easy, conservative measures do not work there are other options. Corticosteroid injections can be done to reduce inflammation. The area around the tendon is injected to reduce inflammation, the tendon itself is not injected as steroid can potentially weaken the tendon. There are a few studies on extracorporeal shock wave therapy in other types of tendon injury and this may be helpful, but it may also decrease strength in the tendon temporarily.

Ultrasound guided percutaneous tenotomy can be done if the above fail. A need is inserted into the tendon and repeatedly passed through the areas of degeneration. This stimulates growth factors and a natural healing process. In addition, PRP (platelet rich plasma) can be injected which add more growth factors.

It is extremely rare for the above to fail, but in those cases there are surgical options to relieve pressure and clean up the tendon.

Often hamstring tendon injuries take many months to treat, which is extremely frustrating for active people. Sometimes runners can modify their training and keep running and others may need to take a break and to concentrate on pool running or biking. Generally, when a runner can run uphill and accelerate without pain, they can more formally return to running. Starting back slowly involves walking/running for several minute blocks for about 20-30 minutes and slowly building to running the entire time and adding total time. If pain reoccurs, back off to the previous stage of return. When you have returned to running, remember to continue the hamstring strengthening to prevent future injuries. Give your hamstrings a little extra love this Valentine’s Day! Here’s hoping you all are staying

healthy!