Proximal hamstring complaints

Hamstring injuries are common in athletes. Quick action and targeted Physical Therapy can potentially make the difference in recovery time. Fysio Fitaal in Tilburg is a Physiotherapy practice in Tilburg that focuses particularly on sports physiotherapy and Physiotherapy after surgery. For the best treatment, we need to know what types of injuries can occur in this part of the hamstring.

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Types of hamstring injuries

Between 12 and 26% of all injuries resulting from sports consist of a hamstring injury. In elite athletes, a hamstring injury itself can determine the further course of a career. Figures for re-injury of the hamstring region run as high as 68%(Diemer et al, 2021). New research shows that factors such as older age and previous injuries have a much greater impact on the risk for a hamstring injury than factors we can influence such as fitness or strength(Green et al, 2020). Other factors also relate to possible variation such as specific location where the hamstring attaches along with variations in muscle turnover. In some cases, there is even the presence of extra muscle in the hamstring(Tubbs et al., 2016). This extra muscle mass allows for more powerful and explosive movement which increases the likelihood of sustaining an injury. In addition to this way of causing muscle injuries in the hamstring(sprint), we also see another mechanism of occurrence in hamstring injuries, which is the stretch type. We see this especially in sports that involve a lot of kicking (whether against a ball or not).

Light to moderate hamstring injuries are often treated with various methods to relieve the pain and eccentric exercise therapy(strength training) to gradually get back to a sport specific load capacity. When treated this way, we often see that the duration of the injury varies greatly along with the degree of resumption of sport at the original level. Treatment of severe hamstring injuries such as an avulsion fracture and severe muscle tendon ruptures often have a poor outcome in terms of full resumption of sport. We also see a structural decrease in strength relative to the unaffected side. Because of the latter, the risk of a new hamstring injury is high. The degree of variability in prognosis and chosen treatment makes a thorough and prompt diagnosis valuable. Also, a better awareness of variations in muscle tissue can lead to a more successful and personalized treatment plan. 

The proximal hamstring region:

When looking at the proximal hamstring region, we can distinguish between different types of injuries to the muscle tendon bone unit of the hamstring. In this blog, we will take you through and show you the added value (quick) ultrasound examination can have on the outcome of symptoms. Making a more accurate diagnosis often allows for a more appropriate and customized treatment plan. 

 

Apophysis-related injuries: 

The site of an injury to the bone-tendon-muscle unit of the hamstring is often related to the age of the person. In younger children, this is the apophyseal region of the tuberositas ischiadicum. This region is the least strong at this age and because of this, there is a chance of an avulsion fracture. An example is acute pain during overplaying a ball during soccer. Not feeling tension of the hamstring on the tuberosity during testing force of extension of the hip increases the chance of an avulsion fracture. Often there is no discoloration as with, for example, a hamstring muscle tear. Stretch tests will also often not be sensitive because during stretching of the hamstring there is no tension on the tuberosity. If a complete avulsion is suspected, the distance between the tuberosity and the retracted tendon should be measured. If this exceeds 2 cm, surgery of the proximal hamstring is considered.

Tendon injuries

A tendinopathy occurs mostly in young adults and are the cause of an acute moment or the result of long-term strain. Most tendon injuries are seen in older adults as a result of normal aging in which tendon tissue generally loses strength. With this injury, the tendon loses its density and ability to transfer energy properly. Because of this, we see a thick (dark area) tendon on the ultrasound image. These symptoms are usually described as a localized pain under the gluteal fold with a nagging radiation to the back of the thigh. The swelling can also stimulate the nerve (sciatic nerve). This then causes a radiating pain. Color Doppler is widely used to map possible tendinopathies. However, this is difficult to confirm in the proximal hamstring region because the tendon of the hamstring lies deeper. The pressure required from the transducer will mask the possible inflammatory response(neovascularization). In some cases, there may be a clicking sound in the hip also called snapping hip. The clicking sound is caused by the tendon moving across the bone. It usually produces a recognizable pain when this happens. Dynamic examination of the hip using ultrasound can confirm this diagnosis. 

There may also be calcium deposition (calcification) in the tendon. During this calcification process, calcium is deposited in the tendon. Why exactly this happens is not yet completely clear. What we do know is that there is no demonstrable reason or direct relationship to: 

  • calcium intake
  • osteoarthritis or osteoporosis in adjacent joints or bone parts
  • heavy physical strain in the past

 Calcifications in the tendon, in most cases, diminish over time or even disappear spontaneously. 

 

Muscle-tendon injuries

In young athletes, we often see injuries to the muscle-tendon transition. A powerful eccentric phase in the hip while the knee makes extension creates a large force on the hamstring muscle-tendon musculature. Resulting in a partial or complete muscle rupture. Clinically, these patients have sharp pain immediately after trauma moment. Ultrasound examination must take place at least 48 hours after the moment of onset because otherwise a detailed view of the muscle structure is not possible due to hematoma. A complete tear can be confirmed by dynamic recording during hamstring tightening. 

 

Possible other forms of symptoms and diagnosis in proximal hamstring pain

A bursa inflammation in this region (bursa ischiadica) can cause similar symptoms similar to a tendon injury of the proximal hamstring. This often produces a nagging pain in the buttock. The image of a bursitis ischiadica shows a large hypoechogenic area with an irregular outline. Deeper thrombosis can possibly also give symptoms of a typical hamstring injury. These symptoms cause a dull pain over the back of the thigh. Ultrasound examination may possibly signal deep venous thrombosis.

 

Do you recognize yourself in any of the above images? Then contact Fysio Fitaal in Tilburg. We are a modern practice Physiotherapy with a focus on sports physiotherapy and physiotherapy after surgery. In addition to our commitment to your rehabilitation and recovery, we use innovative and measurable physical therapy.

 

Currently we have two locations . Our first physiotherapy practice is located in Tilburg Centrum on Veldhovenring 57. Our other location is located in Tilburg Reeshof at Spaubeekstraat 89 in the Basic Fit. 

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