If you work with runners, sprinters, hurdlers, explosive and change-of-direction-focused athletes, you’ve more than likely worked with proximal hamstring tendinopathy. Researchers Thomas Goom and his colleagues (2016) characterize hamstring tendinopathy as “deep, localized pain in the region of the ischial tuberosity that often worsens during or after running, lunging, squatting, and sitting.” Easy enough, right? Unfortunately, there are many ailments that disguise themselves as hamstring tendinopathy and little evidence to direct management. So how is a clinician supposed to diagnose and manage hamstring tendinopathy?
A few months back, the aforementioned researchers set out to determine just that: “The aim of this article is to review clinical aspects of proximal hamstring tendinopathy assessment and management, including differential diagnosis and exercise prescription. Recommendations will be based on current evidence and understanding of pathology and pain in tendinopathy” (2016).
In part one covering this study, we will review the researcher’s recommendations of diagnosis, as well as other conditions to be aware of during the process.
How to diagnose hamstring tendinopathy
The authors recommend a three-step approach to diagnosing proximal hamstring tendinopathy:
- Careful reporting of subjective history
- Screening of other potential pathology
- Utilization of commonly advocated diagnostic tests
Step 1: Subjective assessment
“Subjective assessment of typical tendon pain behavior should confirm well-localized ischial tuberosity pain that becomes less symptomatic after a few minutes of activity but is worse afterward (as well as) pain during activities requiring deeper hip flexion, such as squatting or lunging and sitting for long periods, especially on harder surfaces”(Goom et al. 2016).
The authors also warn that clinicians should be mindful that hamstring tendinopathy symptoms are rarely produced during activities that do not involve energy storage or compression, such as slow walking on a level surface, standing, and lying. “There may be stiffness in the morning or when starting to move after prolonged rest. Some pain provocation after energy storage activities may be acceptable during rehabilitation, providing it lasts no longer than 24 hours” (Goom et al. 2016).
Step 2: Screening of other potential pathology
Keep in mind that other conditions could be the cause of reported symptoms. Goom and colleagues warn clinicians to be on the look out for some of the differential diagnosis, such as:
- Sciatic nerve irritation at the piriformis muscle or near the ischial tuberosity
- Ischiofemoral impingement
- Unfused ischial growth plate in a postadolescent athlete
- Apophysitis or avulsion among adolescents
- Deep gluteal muscle tear
- Posterior pubic or ischial ramus stress fracture
- Partial or complete rupture of the proximal hamstring tension
Step 3: Diagnostic tests for hamstring tendinopathy
In terms of the basis of diagnosing proximal hamstring tendinopathy, it is recommended that clinicians start by correctly increasing tension of the hamstring. “The principle is to reproduce pain by placing the proximal hamstring tendons under progressively increasing compressive and tensile load by increasing hip flexion angle” (Goom et al. 2016). Examples of a load test assessments include the following progression:
- Single-leg bent-knee bridge (a low-load test)
- Long-lever bridge (moderate load)
- Arabesque movements and the single-leg deadlift (high-load)
There are also three passive stretch tests that the authors found to have moderate to high validity for diagnosing the impairment:
- Bent-knee stretch
- Modified bent-knee stretch
- Puranen-Orava test
“A recent systematic review suggests that higher-quality studies are warranted to investigate the clinical utilization of special tests for the diagnosis of hamstring injuries. This reinforces the importance of combining test results with a detailed history to determine tendon pain behavior in diagnosing proximal hamstring tendinopathy” (Goom et al. 2016).
In part two, we will take a closer look at how to determine a treatment approach to hamstring tendinopathy. Subscribe to the Performance Health Academy to make sure you don’t miss the rest of the series!
Goom T et al 2016. Proximal Hamstring Tendonopathy : Clinical Aspects of Assessment and Management. Journal of Orthopaedic & Sports Physical Therapy. 2016;46(6):483-493.