Proximal hamstring tendinosis

What is proximal hamstring tendinosis?

Proximal hamstring tendinosis refers to inflammation of the hamstring tendon attachment to the ischial tuberosity (the sit bone). The pain is typically located at the buttock crease and can extend to the back of the upper thigh. Proximal hamstring tendinosis can affect all age groups. It can be seen in sports persons (like runners and footballers), usually related to a sports injury/strain. In such cases, the condition can be frustrating, persisting for several months and interfering with sports and activities. Hamstring tendinopathy is also seen in the elderly with a sedentary lifestyle causing buttock pain, mainly felt when sitting on hard surfaces.

Relevant anatomy

The hamstring is the large group of muscles that run at the back of the thigh. They consist of three muscles “the biceps femoris, the semimembranosus, and semitendinosus muscles”. These muscles have a common tendon that attaches to the ischium or ischial tuberosity (the sit bone). This tendon is called “the proximal hamstring tendon”. The hamstring is the primary muscle responsible for hip extension and knee flexion. They undergo significant stress during sports activities involving sudden acceleration and direction changes (like football and sprinting).

What are the causes of proximal hamstring tendinosis?

Usually, proximal hamstrings tendinosis is a repetitive overload-type injury resulting from repeated exposure to excessive stress over a long period of time. This can happen particularly if the tendon does not have sufficient time to recover between these episodes of high energy demands. This would cause tendon inflammation, “tendonitis”, resulting in pain and weakness. Repeated tendonitis would interfere with the tendon's normal healing/recovery process. As a result, the proximal hamstring tendon will become thickened and swollen. This process is referred to as “hamstring tendinopathy”.
Proximal hamstring tendon pain can result from a specific injury sustained during sports (like football and running). This can result in a tendon tear. Ultrasound assessment is very useful here to assess the extent of the tear. Hamstring tendon tears tend to heal over time, with adequate rest but can result in chronic tendinopathy.
Direct pressure upon the tendon from sitting on hard surfaces is also a common cause of proximal hamstrings tendon pain and inflammation.

What are the clinical features of proximal hamstring tendinosis?

Proximal hamstring tendinopathy usually results in:

Sharp pain deep to the buttock over the sitting bone.
The pain is worsened with activity and improves with rest. It can also be worse after sitting or driving.

What is ischio-gluteal bursa/bursitis?

The ischio-gluteal bursa is a small sac containing fluid that can form adjacent to an inflamed hamstring tendon attachment to the ischial tuberosity (the sit bone). It is part of the body's attempt to provide support and cushioning around the inflamed tendon. Bursitis refers to irritation of the bursa associated with accumulating inflammatory cells. Therefore, the condition is usually painful. Ultrasound is an excellent modality to assess the ischio-gluteal bursa and the adjacent hamstring tendon. An ultrasound-guided steroid injection can be helpful in the management if conservative treatment is not successful.

What conditions can mimic proximal hamstring tendinosis?

Proximal hamstring tendinosis is the main cause of pain at the back of the hip/upper thigh. It should not be confused with other more common causes of pain at the front of the hip, including:

Proximal hamstring tendinosis can be mistaken for:

Trochanteric bursitis
Pain radiating from the back/sciatica. This is usually associated with backache, and the pain extends lower within the thigh. Such findings could indicate the presence of nerve entrapment within the back. A lower (lumber spine) MRI would be very useful to establish the diagnosis.
Sacroiliac joint pain. This is usually felt higher up in the back. For more information, please see our article about sacroiliitis.

Proximal hamstring tendinosis vs hip trochanteric bursitis

Both conditions are primarily due to tendon abnormalities. Trochanteric bursitis (or greater trochanteric pain syndrome) is due to inflammation (tendinosis) of the gluteal tendons. The main differentiating feature is the site of the pain. Proximal hamstring tendinosis pain is usually felt deep to the buttock and at the upper thigh. Trochanteric bursitis pain is felt more at the side of the hip, over a bony prominence (called the greater trochanter).

How to diagnose proximal hamstring tendinosis?

Detailed clinical assessment by a specialist orthopaedic doctor is essential. Imaging can be used to confirm the diagnosis and assess the severity of the condition. Ultrasound is usually the first imaging modality used for the assessment. It will answer the following questions:

Is there any tendon inflammation?
Is there any tear to the proximal hamstring tendon? If yes, then it will assess the grade and size of the tear.
Any features of ischio-gluteal bursitis? Ultrasound guidance is extremely useful when performing a steroid injection into the ischio-gluteal bursa. A plethora of evidence shows that injections done under ultrasound guidance result in better outcomes, with better pain relief and improved function.

A hip MRI examination will also help assess the hamstring tendon and muscles for any injury or inflammation.

What is the treatment for proximal hamstring tendinosis?

Management is mainly conservative, using physiotherapy. This usually consists of a progressive loading program as well as soft tissue manipulation techniques. A short period of rest prior to the program might be needed, if there is an injury to the tendon. Complete rest/abstinence from sports activities is usually not indicated, as there is no evidence to support its effectiveness in the management of proximal hamstring tendinopathy. Oral anti-inflammatory tablets can be also useful in the management.

It is important to know that the management of tendinopathies is a slow process, so you need to be patient.

What are the options if physiotherapy is not helping in the management of proximal hamstring tendinosis?

If the above conservative measures do not result in a satisfactory response, then an ultrasound-guided injection can be considered. This usually consists of a small dose of steroid injected close to the proximal hamstring tendon or the inflamed ischio-gluteal bursa. This should reduce inflammation and provide a window of opportunity to help you achieve more effective rehabilitation.

Should injections for proximal hamstrings tendinosis be done under ultrasound guidance?

Yes. This is our routine practice as there is plenty of evidence supporting the use of ultrasound guidance when performing musculoskeletal injections. Doing injections under ultrasound/imaging guidance allows for direct visualization of the needle to ensure accurate placement into the area of pain/inflammation (like a bursa, an arthritic joint, or an inflamed tendon sheath). Ultrasound guidance results in more accurate, less painful, and faster procedures, with better outcomes, compared to doing these injections without guidance. Ultrasound guidance ensures the avoidance of any sensitive structures (like nerves and vessels) during the procedure.

What are the possible side effects of a steroid injection?

Generally, these injections are very safe and routinely done in our practice. There is a very small risk of infection (about 1:10.000). The injected area may feel sore for the first few days. This is referred to as (steroid flare) and can be seen after a steroid injection. The procedure will be explained to you in detail during your appointment and all your questions will be addressed. To find out more about cortisone injection in general, please see our FAQs.

How long will the effect of a cortisone injection last?

Current evidence suggests that cortisone can improve pain and function for up to 3 months, but in some cases, it can last longer. The injections usually also contain a local anaesthetic that provides immediate pain relief lasting a few hours.

How soon will a steroid injection start to work?

A steroid injection usually takes a few days (1-3) before you notice the effect, although sometimes the pain relief can start on the same day. More commonly, the injected area will feel sore for the first few days. This is referred to as (steroid flare) and can be seen after a steroid injection.

How many steroid injections can I have for proximal hamstring tendinosis?

We advise reducing the number of cortisone injections if possible, by combining any injection therapy with an effective physiotherapy program to address the underlying cause. Repeated steroid injection into the same area should be avoided if the previous injection was less than 3-4 months ago.

How long should I rest after a hip steroid injection?

Usually, we advise patients to rest for 48-72 hours after having a hip injection. This can vary depending on the type of treatment and severity of the condition. Usually, patients who have a steroid injection are usually advised to rest for 48 hours.