HS Tendinopathy Rehab Goom

1 Proximal Hamstring Tendinopathy: clinical aspects of assessment and
2 management
3
4 Goom T, Malliaras P, Reiman MP, Purdam C
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6
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8 Thomas S.H. Goom, BSc (Hons), MCSP
9 Clinical Lead
10 The Physio Rooms
11 Brighton
Downloaded from www.jospt.org at The University of Melbourne - Faculties on April 16, 2016. For personal use only. No other uses without permission.
12 England
13 tomgoom@gmail.com
14
15 Peter Malliaras, BPhysio (Hons), PhD
16 Clinical Director, Complete Sports Care, Melbourne, Australia
17 Adjunct Researcher, La Trobe University, Melbourne, Australia
18 peter@completesportscare.com.au
19
20 Michael P. Reiman, PT, DPT, OCS, SCS, ATC, FAAOMPT
21 Assistant Professor
22 Duke University Medical Center
23 Department of Orthopaedics
Copyright © ${year} Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
24 reiman.michael@gmail.com
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27 Craig R. Purdam, MSports Physio, FACP, FASMF
28 Head, Physical Therapies, Australian Institute of Sport
29 Adjunct Professor, School of Physiotherapy, University of Canberra
30 craig.purdam@ausport.gov.au
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Journal of Orthopaedic & Sports Physical Therapy®
33 Corresponding author: Tom Goom, The Physio Rooms, Brighton Health and Racquets
34 Club, Village Way, Falmer, Brighton, England, BN1 9SG.
35 tomgoom@gmail.com
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38 Word count: 5,092
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42 Proximal Hamstring Tendinopathy: clinical aspects of assessment and
43 management
44
45 I affirm that I have no financial affiliation (including research funding) or involvement with
46 any commercial organization that has a direct financial interest in any matter included in this
47 manuscript, except as disclosed in an attachment and cited in the manuscript. Any other
48 conflict of interest (i.e., personal associations or involvement as a director, officer, or expert
49 witness) is also disclosed in an attachment.
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52 Acknowledgments
Smith and Robyn Lorraway, for their assistance in preparing figures1 through 6.
The authors wish to thank Kate Smith, Mike Boyce, David Beltramo, Lloyd Harris, Ross
58 Abstract
59
60 Background: Proximal hamstring tendinopathy (PHT) typically manifests as deep buttock
61 pain at the hamstring common origin. Both athletic and non-athletic populations are affected
62 by PHT. Pain and dysfunction are often longstanding and limit sporting and daily functions.
63 There is limited evidence regarding diagnosis, assessment and management, for example,
64 there are no randomized controlled trials investigating rehabilitation of PHT. Some of the
65 principles of management established in, for example, Achilles and patellar tendinopathy
66 would appear to apply to PHT but are not as well documented. This narrative review and
67 commentary will highlight clinical aspects of assessment and management of PHT, drawing
68 on the available evidence and current principles of managing painful tendinopathy. The
69 management outline presented aims to guide clinicians as well as future research.
70
71 Key Words; tendon, evaluation, treatment.
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96 Introduction
97 Proximal hamstring tendinopathy (PHT) is common among distance runners and athletes
98 performing either primarily sagittal plane (e.g. sprinting, hurdling) or change of direction
99 activities (e.g. various football codes and hockey).35, 50 It can also affect people who do not
100 participate in sport,28, 50, 70 and not uncommonly presentation is bilateral in this demographic.
101 Characteristics of PHT include deep, localised ischial tuberosity region pain that is often
102 worse during or after running, lunging, squatting and sitting. Diagnosis can be challenging as
103 tendinopathy of the hamstring origin is one of several potential sources of symptoms in this
104 region. To date, there is very limited evidence to guide management. The aim of this article is
105 to review clinical aspects of PHT assessment and management, including differential
106 diagnosis and exercise prescription. Recommendations will be based on current evidence and
107 understanding of pathology and pain in tendinopathy.

108
109 Anatomy
110
111 The hamstring muscles have a common origin on the lateral aspect of the ischial tuberosity.
112 Semitendinosus and the long head of biceps femoris share a conjoined tendon originating
113 from the lateral facet, whereas the semimembranosus origin is deeper, 68 although anatomical
114 variation is reported. 34
115
116 The location of hamstring tendon pathology may vary; Lempainen et al.50 reported
117 semimembranosus pathology in all cases while Benazzo et al.10 found considerable
118 variability (common hamstring tendon 23%, biceps femoris 41%, semimembranosus 29%
119 and semitendinosus 6%). Mid-portion tendinopathy in PHT has not been specifically reported
120 in the literature although this may comprise a part of the cohort described by Lempainen.50
121 Mid-portion pathology more typically involves semimembranosus and may be distinct from
122 the acute partial or complete tears in this region described by Askling et al.6, 7
123
124 Proximal hamstring tendinopathy is considered to be an insertional tendinopathy and
125 compression of the tendon at its attachment during hip flexion/adduction is thought to be a
126 key etiological factor.25 Evidence supporting this theory is limited as patho-anatomical
127 studies of the proximal hamstring tendons are sparse.34 Shear force between the hamstring
128 attachment and ischial tuberosity has been reported when replicating in vivo loading37 as well
129 as increased displacement of proximal hamstring tendon with increased hip flexion angle.39
130 Further research is required to better define the nature and degree of tendon compression in
131 functional activities.
132
133 Etiology
134
135 Etiology of tendinopathy is multifactorial involving load related extrinsic and intrinsic
136 factors. Extrinsic factors include training errors such as increasing volume or intensity too
137 quickly, particularly the sudden introduction of sprint work, lunging, hurdles or hills. Several
138 case series43, 97 have been identified that report these training errors to precede PHT. These
139 activities require the hamstring to contract or lengthen whilst in hip flexion and may result in
140 provocative tensile and compressive load at the tendon insertion.30, 88 Symptoms may also
141 occur due to excessive use of static stretches, for example in yoga and Pilates involving
142 sustained end range hip flexion postures. In some patients compressive load simply from
143 sitting is the main load inciting factor.49
144
145 Systemic factors may also influence risk of PHT. These are suggested to include genetic
146 polymorphysms (e.g. COL5A1 that encodes for collagen type V), age, Body Mass Index,
147 metabolic issues (e.g. lipid level imbalance, glucose intolerance, insulin resistance), hormonal
148 changes and rarely, medication (e.g. fluoroquinolone antibiotics)9, 51, 94 all of which may
149 increase risk of developing tendinopathy.2. Peri-menopausal females with PHT are likely to
150 have a systemic predisposition to their tendon pain, as loss of estrogen at menopause is
151 thought to negatively influence tendon homeostasis.38 Systemic factors are thought to reduce
152 the threshold for tendon pain and pathology from load-related factors.
153
154 Hamstring function
155
156 An understanding of hamstring muscle function is important in PHT rehabilitation. In upright

157 running, which can be a key aggravating factor in athletic populations, the hamstrings
158 eccentrically decelerate knee extension in terminal swing phase. Peak force occurs in late
159 swing, with a second peak reported in early stance.19, 36
160
161 Energy storage in the late swing to early stance stretch-shorten cycle is likely to be a major
162 contributor to hamstring origin overuse injury and eccentric-concetric transition is associated
163 with higher hamstring loads.81 Elastic energy storage in the tendons and aponeuroses
164 increases efficiency of locomotion at higher speeds in animals.3 The hamstring origin may be
165 subject to higher energy storage loads in greater hip or trunk flexion, for example, when
166 running with forward trunk lean, over-striding and during uphill running.
167
168 Given these functional requirements, eccentric bias and stretch-shorten cycle exercise have
169 been recommended by some authors for hamstring muscle injury to facilitate muscle
170 hypertrophy, strength and length-tension changes (greater strength nearer to end range),56 as
171 well as return to sport.8, 90
172
173 Pathology and pain
174
175 The pathological features in PHT are similar to those seen in common tendinopathies such as
176 the Achilles and patellar tendon.50 Tissue samples from pathological proximal hamstring
177 tendons show increased cellularity, ground substance accumulation, collagen disorganization,
178 and neurovascular ingrowth.50 Cook and Purdam22 recently proposed the continuum model of
179 tendon pathology, where diffuse increased cellularity and ground substance (reactive
180 tendinopathy) precedes focal areas of collagen disorganization and neurovascular ingrowth
181 with progression over time to a morphology with discrete islands of degenerative
182 tendinopathy. Malliaras et al.55 demonstrated an ordinal progression of patellar tendon
183 ultrasound imaging pathology from diffuse (reactive) to localised (degenerative) changes
184 among volleyball athletes. There is no evidence of similar structural groups on imaging in
185 PHT. Most studies report localized tendon pathology at the enthesis, bone edema and
186 insertional tendon clefts.11, 29, 49 As with the Achilles, patellar and other tendinopathies,
187 asymptomatic tendon pathology is not uncommon. Alternatively, a clinical diagnosis of PHT
188 without significant demonstrable pathology is also possible.29 Treatment focus in early
189 presentation should therefore be on managing pain. The exact source of pain generation in
190 tendinopathy is yet to be identified. The reader is directed elsewhere77, 82 for a comprehensive
191 discussion of potential tendon pain mechanisms.
192
193 Subjective assessment and screening of other potential pathology
194
195 Diagnosis of PHT is complex, requiring careful elucidation of subjective history, screening
196 of other potential pathology and utilization of commonly advocated diagnostic tests.
197 Subjective assessment of typical tendon pain behaviour should confirm well localized ischial
198 tuberosity pain that becomes less symptomatic after a few minutes of activity (e.g. ‘warms
199 ups’ when running) but is worse afterwards.
200
201 Activities requiring deeper hip flexion such as squatting or lunging and sitting for long
202 periods, especially on harder surfaces, are often provocative. Proximal hamstring
203 tendinopathy is rarely painful during activities that do not involve energy storage or
204 compression such as slow walking on a level surface, standing and lying. There may be
205 stiffness in the morning or when starting to move after prolonged rest.
206
207 Some pain provocation after energy storage activities may be acceptable during
208 rehabilitation, providing it lasts no longer than 24 hours.45, 85 Pain provocation of greater than
209 24-hours may be defined as 'irritable', while pain that settles within 24-hours of energy
210 storage loading can be defined as 'stable'.54 After an initial ‘warm up’ stable tendon pain may
211 return towards the end of activity
212
213 More diffuse symptoms may indicate lumbar, hip or sacroiliac joint (SIJ) somatic referral,
214 radiculopathy or sciatic nerve compromise in the buttock, which is a common co-morbidity
215 given its proximity to the hamstring origin.32, 61, 69 Multiple pathologies that may also give
216 buttock symptoms need to be considered in differential diagnosis (see BOX 1). These
217 pathologies often present with atypical tendon pain behavior (e.g. more diffuse pain,
218 aggravating factors are less specific to high hamstring load in hip flexion) and can be
219 screened with provocative tests (e.g. SIJ provocation tests, repeated motions of lumbar spine,
220 straight leg raise test, slump test, provocation tests for sciatic nerve entrapment and hip
221 impingement testing),14, 31, 47, 57, 72, 73, 89, 96 specific differential palpation and imaging. Not
222 uncommonly in more chronic presentations apparent isolated hamstring pathology may
223 coexist with other pathologies, adding further complexity to both diagnosis and management.
224
225 Partial or complete proximal hamstring ruptures may also cause buttock symptoms.
226 Importantly, partial or complete proximal hamstring ruptures are characterised by an acute
227 onset with a mechanism of extreme hip flexion combined with knee extension and often
228 accompanied with an audible ‘pop’.7 Partial proximal hamstring ruptures can be managed in
229 a similar manner to PHT, with a graded loading programme based on symptoms, but are
230 associated with a prolonged recovery time.7 Askling et al.6 describes a comprehensive review
231 of the management of complete and partial proximal hamstring ruptures.

232
233 Clinicians should be aware of psychosocial factors that may influence pain and management
234 of PHT and adopt a biopsychosocial approach where appropriate. Patients may have
235 erroneous beliefs (e.g. pain is damaging, pathology is serious and will limit improvement,)
236 that may be associated with heightened attention, anxiety and fear avoidance.5 Central
237 sensitisation, an amplification of neural signalling within the CNS that elicits pain
238 hypersensitivity,99 may also be a factor. Bilateral sensory changes that may reflect medium
239 term central nervous system modulation have been reported in tendinopathy, potentially
240 indicating central sensitization,77 although this has not been investigated in PHT. This
241 highlights that pain is not simply tendon nociception but a complex output that is influenced
242 by many factors. Symptoms that would raise the suspicion of central sensitisation include
243 diffuse pain without a clear stimulus-response relationship,87 secondary hyperalgesia77 and
244 pain that is disproportionate to the nature or extent of the injury.66 Questionnaires, such as the
245 Central Sensitisation Inventory and Pain Sensitivity Questionnaire may assist in the diagnosis
246 and assessment of central sensitisation.59, 65, 79 The role of psychosocial factors and central
247 sensitisation has not been studied extensively in tendinopathy and is a key area for further
248 research to complement recent work in this field by Woolf99 and Nijs.66
249
250 Diagnostic tests

251
252 Pain with provocative loading tests may assist in the diagnosis of PHT but further research is
253 required to confirm the diagnostic accuracy of such tests. The principle is to reproduce pain
254 by placing the origin of the hamstring tendons under progressively increasing compressive
255 and tensile load (by increasing hip flexion angle). An example of a load test assessment for
256 these patients may consist of progression from the single leg bent knee bridge (a low load
257 clinical test FIGURE 1A) to the long lever bridge (moderate load test FIGURE 1B) and
258 arabesque (FIGURE 1C) movements to the single leg deadlift (a high-load clinical test).26
259 These motions may be initiated slowly initially, adding speed if asymptomatic. Pain score
260 should increase with load across these tests.

261
262 Three passive stretch tests (bent-knee stretch, modified bent-knee stretch and Puranen-Orava)
263 have moderate to high validity and high sensitivity and specificity for diagnosis of PHT.15
264 However, in the authors’ experience, these tests may be negative in less symptomatic cases.
265 Other clinical conditions may be responsible for reported symptoms and the use of MRI is
266 recommended.15 In addition, clinically, pain response to palpation appears to vary and may
267 have low specificity for diagnosing tendinopathy.24
268
269 A recent systematic review suggests higher quality studies are warranted to investigate the
270 clinical utilization of special tests for the diagnosis of hamstring injuries.74 This reinforces the
271 importance of combining test results with a detailed history to determine tendon pain
272 behaviour in diagnosing PHT.
273
274 Identifying Impairments, Activity Limitations & Participation Restrictions for

275 Determination of Treatment Approach
276
277 Further assessment to determine possible musculoskeletal intrinsic factors that may
278 contribute to increased provocative load on the proximal hamstring tendons is pertinent.
279 Broadly, this may include assessment of joint range of motion, strength, co-ordination, and
280 functional tasks and should be related to the sporting/ work/ leisure demands of the individual
281 patient. While impairment findings in the hip have demonstrated limited diagnostic value,72,
73, 75
282 they can be valuable in guiding treatment.75
283
284 Single leg squatting is assessed in regards to pain and function, including coronal/frontal and
285 sagittal plane movement patterns. Excessive lumbo-pelvic sagittal plane movement (i.e.
286 anterior tilt and hip flexion) has been linked to hamstring muscle injury41, 42, 58 with
287 suggestion of increased stress at the hamstring origin.67 This reasoning may support the
288 inclusion of trunk stabilisation/ strengthening exercises which have been utilized in a multi-
289 modal management approach to PHT.27, 43 However, there are challenges in the accurate
290 measurement of lumbo-pelvic movement in a clinical setting.80 In principle, a more
291 posteriorly tilted pelvis position will reduce hamstring stretch during function,36 hence
292 interventions directed at reducing anterior pelvic tilt (in standing, sitting or running) have the
293 potential to reduce provocative hamstring load.

294
295 Running or walking gait analysis, or sports specific movement pattern assessment is critical
296 in management of PHT. Over-striding, excessive forward trunk lean and increased anterior
297 pelvic tilt are clinical findings that may increase provocative load on the hamstring origin
298 tendons. Increasing running step rate reduces stride length and hip flexion at foot strike40 and
299 increases gluteal activity in terminal swing.20 Whilst this intervention has the potential to
300 reduce provocative hamstring tendon load, the role of running gait retraining has not been
301 studied in treatment of PHT.
302
303 Patients may present with hamstring weakness and atrophy, often in relation to long-standing
304 symptoms. Case series have reported hamstring weakness on manual testing 43 and reduced
305 knee flexion and hip extension strength60 in athletes with PHT. Hand held or fixed
306 dynamometry may be used to assess hamstring strength.44, 92, 97, 98 In the absence of these
307 instruments the authors suggest testing strength in a leg curl machine to preferentially isolate
308 the hamstring muscles, as a loaded hamstring curl achieves high levels of biceps femoris and
309 semitendinosus activity with minimal gluteus maximus recruitment.4

310
311 Other kinetic chain deficits have the potential to increase hamstring origin stress
312 concentration. Gluteus Maximus (GMax) atrophy has been reported in PHT and is thought to
313 contribute to proximal hamstring overload.28 Gluteus maximus weakness may be measured
314 with handheld dynamometer although this may be a challenge in stronger athletes.92
315 Weakness of gluteus medius (GMed) has been associated with PHT43, 97 as a result of an
316 increase in hip adduction and/or contralateral pelvic drop during squatting or lunging.
317
318 Adductor magnus is a significant hip extensor through a large range of hip flexion91 and its
319 muscle fibres are intimately related to the origin of semimembranosus,68 hence, assessment of
320 adductor function may also be warranted. Distal kinetic chain weakness or restriction and
321 quadriceps dysfunctions are less common although should be considered.
322
323 Hamstring flexibility, (range of motion) appears to vary considerably. Greater hamstring
324 tensile stress and absorbed energy has been reported at end range among flexible compared
325 with less flexible people,52 which may increase entheseal compression and injury risk in
326 populations that stretch already flexible hamstrings repetitively (yoga).
327
328 The current status of limited research into tendon loads, muscle actions and synergies relating
329 to the hamstring origin region, as well as a deeper understanding and robust assessment of
330 kinetic chain dysfunction is also worthy of mention.
331
332 Patient-reported outcome measures (PROs)
333
334 Recently the Victorian Institute of Sport Assessment (VISA) pain and function outcome
335 questionnaire has been adapted for the hamstring origin.16 This is an appropriate outcome
336 measure with high reliability and validity.16 However, where within-session assessment of
337 pain is required, a visual analogue scale rating of provocative functional tests (e.g. long or
338 short lever bridge, single leg bent knee bridge, or later in rehabilitation the arabesque and/or
339 single leg deadlift) is preferable for immediate symptom response to exercise or other
340 interventions. A patient specific functional scale rating of key functional deficits can also be
341 used for within and between session assessment.
342
343 Symptom Management- Load modification
344
345 Training load modification is critical in managing pain in patients with irritable symptoms. In
346 practice, abusive compressive (hip flexion) and energy storage loads are limited until pain
347 irritability settles to a stable level. ‘Stable’ pain should be mild (e.g. VAS 0 to 3 out of 10)
348 and settle within 24 hours of a moderate to high tendon load intervention such as repeated
349 lunging. Therefore, a key subjective question in determining irritability and effective load
350 management is ‘what activities increase your symptoms and for how long?’ Not uncommonly
351 the patient may be able to continue some steady state running, within pain/aggravation
352 guidelines, however hills, starts and hurdles should be avoided until later stages.
353
354 Silbernagel84 found that continuing sport activities did not lead to worse Achilles
355 tendinopathy rehabilitation outcomes compared to stopping sport activities in the first 6
356 weeks. This seems to be in contrast to the patellar tendon though.95 Runners will often report
357 distances they are able to run symptom free, or where pain is only present during certain
358 types of training (e.g. change of direction or squats). If, despite partial load management,
359 symptoms are still reacting for greater than 24 hours then cessation of the identified
360 provocative elements within the sport may be advisable. In truly reactive or irritable patients,
361 all painful compression and energy storage activity will need to be ceased until symptoms
362 settle and become stable.
363
364 Provocative sporting activities can be temporarily replaced with cross-training to maintain
365 cardiovascular fitness or adapted to reduce compressive loading. For example, cycling may
366 be better tolerated if performed in a standing position. Swimming and water running are
367 viable alternatives to painful activities. Posture modification should involve reducing
368 hamstring origin compression (i.e. reducing anterior pelvic tilt and hip flexion in standing,
369 sleeping and sitting). Shaped cushions can be useful for reducing compression in sitting, as is
370 encouraging more weight bearing on the posterior thighs rather than the ischium. Repeated
371 stretching of the hamstrings and hip flexion dominant movement patterns, such as repetitive
372 lifting and trunk flexion, should be avoided in the early, reactive phase.
373
374 Rehabilitation
375
376 The key to management of all tendinopathies is progressive loading, performed within a pain-
377 monitoring framework, to reduce pain and restore function. Rehabilitation should be directed
378 across the kinetic chain and can be progressed to include energy storage and release to
379 normalise load capacity in the entire lower limb.23

380
381 At present there is no clear guidance from the literature regarding PHT rehabilitation.
382 Loading exercises for PHT have not been investigated in randomised controlled trials.
383 Limited case series and case presentations have been published, which demonstrate
384 improvements in pain and function with conservative management including hamstring
385 strengthening.27, 35, 43, 60, 97 Results from these studies cannot be generalised however, due to
386 small patient numbers, varying diagnostic methods and the use of adjunct interventions
387 alongside exercise.
388
389 Exercise prescription
390
391 Rehabilitation stages in PHT, based on the authors synthesis of available evidence of
392 hamstring function, muscle recruitment during rehabilitation and PHT patho-etiology will be
393 outlined below. Resistance training principles should be applied to ensure optimal loading,
394 contraction speed and time under tension.1
395
396 The authors recommend monitoring pain at the same time daily with a load test (e.g. short or
397 long lever bridge, arabesque) during rehabilitation. Some pain is acceptable during and after
398 exercise (VAS 0 to 3 out of 10),45 but symptoms should settle within 24 hours and should not
399 progressively worsen over the course of the loading program.84 Every patient presents
400 individually and this may necessitate a focus on particular phases of rehabilitation or kinetic
401 chain factors.
402
403 Progression through the stages described below is based on symptoms and response when
404 progressing the exercise load rather than specific time frames. It is anticipated that the 4 stage
405 programme will take 3-6 months to complete but there is likely to be considerable individual
406 variation depending on pain and functional deficits.
407
408 Stage 1 – isometric hamstring load
409
410 Resisted isometric exercise in positions without tendon compression is advocated as an
411 effective means to load the muscle tendon unit and reduce pain in PHT with irritable
412 symptoms.26 Isometric exercise has been shown to have a generalized pain inhibitory
413 response.64 Rio et al.77 found that 5 sets of 45 second holds of moderate resistance isometric
414 exercise performed at 70% MVIC reduced patellar tendon pain for at least 45 minutes and
415 provided longer relief than isotonic exercise. Cook and Purdam22 recommend repeating the
416 isometric exercise several times per day. Dosage should be based on symptom severity and
417 irritability with shorter/ less intense contractions used as necessary. For early stage PHT it is
418 suggested the hip should be near neutral hip flexion-extension position or in minimal hip
419 flexion (e.g. 20-30 degrees for straight leg pull downs). A good prognostic sign for isometrics
420 is an immediate reduction in pain with hamstring loading tests post exercise.
421
422 Examples of appropriate exercises for this stage include isometric leg curl, bridge holds with
423 hip in neutral, isometric straight leg pull down and trunk extensions (FIGURE 2). Isometric
424 long leg bridging on two, progressing to one leg holds are a useful alternative if access to
425 gym equipment is limited.
426
427 Stage 2 – isotonic hamstring load with minimal hip flexion
428
429 Isotonic load may be introduced when there is minimal or no pain (VAS 0 to 3) encountered
430 during exercise loading through early ranges of hip flexion. The aim is to restore hamstring
431 strength, bulk and capacity in a functional range of motion, all important aspects in
432 rehabilitation of tendinopathy.83
433
434 Eccentric exercise has been widely accepted as the treatment of choice for tendinopathy12
435 however there is little evidence for isolating the eccentric component.53 Heavy Slow
436 Resistance training (HSR), which includes both concentric and eccentric components, has
437 been found to compare favourably with isolated eccentric loading in the Achilles and patellar
438 tendons. In Achilles tendinopathy, Beyer et al.12 found both loading strategies resulted in
439 improvement in pain and function but HSR took considerably less time to complete and had
440 better patient compliance and satisfaction. Load magnitude determines the effect on tendon
441 (and muscle) adaptation rather than contraction type13 and HSR was shown to achieve greater
442 collagen turnover than sub-maximal eccentric loading.45 As a result HSR is preferred over
443 isolated eccentric loading, although it should be noted, neither has been studied extensively in
444 PHT.
445
446 The focus, with HSR, is on slow fatiguing resisted isotonic exercise, commencing at 15RM
447 (the maximum load that can be lifted 15 times in a single set) and progressing to 8 RM, 3-4
448 sets performed every other day.1 Contraction duration of 3 seconds for each phase (concentric
449 and eccentric, 6 seconds total) of the exercise is recommended.45, 46 A metronome may be
450 used to externally pace the exercise, introducing a skill based element that may improve
451 motor control.76
452
453 Loaded hip flexion is minimized in early stages to protect the enthesis against compressive
454 stimulus.25 Single leg work is important to address asymmetrical strength loss. It is
455 recommended the stage 1 exercises can be continued on the ‘off’ days, particularly if
456 symptoms are still present and isometrics have an immediate positive effect on symptoms.
457
458 Suitable exercises in this stage include: single leg bridge, prone hip extension, prone leg curl,
459 Nordic hamstring exercise, bridging progressions, and supine leg curl (FIGURE 3). Single
460 leg bridge achieves moderate to high levels of activation of hamstrings, GMax and GMed33
461 and can be progressed by adding load (e.g. weight plate over the pelvis) or bridging with a
462 more extended knee. Supine leg curl, prone leg curl and nordic hamstring exercise all achieve
463 very high levels of hamstring recruitment with peak activity typically occurring at between 0
464 and 20° hip flexion4, 100 making them well suited to this stage.
465
466 Stage 3 - isotonic exercises in positions of increased hip flexion (70 - 90°)
467
468 The goal of stage three is to continue hamstring muscle strength, hypertrophy and functional
469 position training, whilst progressing into greater hip flexion. This training can be commenced
470 when there is minimal pain (VAS 0 to 3) with higher loading hip flexion tests, (e.g. lunge or
471 arabesque through the ranges utilized in the athlete’s sport). Dosage and frequency of loading
472 exercises are the same as stage two exercises, i.e. every second day. Slow and controlled
473 technique is important. Addition of loaded hip flexion may often be provocative and pain
474 with loading should be monitored 24 hours post exercise with hamstring load tests into hip
475 flexion (e.g. hamstring bridge, deadlift or single leg arabesque ).26 Progressing to 70-80
476 degrees of loaded hip flexion is generally sufficient, but this will depend on individual pain
477 presentation and functional goals.
478
479 Progression of exercises in this stage may include slow hip thrusts, forward step-ups, walking
480 lunges, deadlifts, Romanian deadlift and ‘the diver’ (FIGURE 4). Some of these are
481 potentially not suitable for less active demographics. Hip thrusts are similar to bridges but
482 involve a greater emphasis on hip flexion range with foot flat on the floor and shoulders
483 supported on a low bench (FIGURE 4D). EMG data suggests high levels of activation in
484 upper and lower GMax, which exceeds that of biceps femoris during this exercise.21 Forward
485 step up using a progressively higher step is a useful progression and can produce very high
486 GMax activation levels.71 Adding load recruits biceps femoris, GMed and significantly
487 increases GMax activation,86 suggesting this exercise is a significant muscular challenge to
488 the entire posterior kinetic chain. Deadlifts and lunges are a further progression as they
489 generally involve greater hip flexion than hip thrusts and step ups. Lunges have been found to
490 selectively recruit the proximal regions of biceps femoris (long head) and adductor magnus
491 on functional MRI analysis.62 Single leg deadlifts increase lateral hip stabilization demands
492 and has been shown to achieve high level activation of the GMax and GMed.71 The diver is a
493 single leg functional progression of the deadlift that has been advocated in hamstring muscle
494 injury rehabilitation.8 Walking lunges (FIGURE 4C) also introduce a dynamic movement
495 control element and can be considered when strength and control with prior exercise is
496 adequate. At the end of this phase loading of the hamstring origin through sports-specific
497 ranges should be comfortably achieved with little latent provocation.
498
499 Stage 4 – energy storage loading
500
501 Stage 4 is only required for those returning to sports involving lower limb energy storage or
502 impact loading. Reintroduction of power/ elastic stimulus for the myotendinous unit can be
503 commenced when there is minimal pain (VAS 0 to 3 during load tests e.g. arabesque) and
504 adequate bilateral strength in single leg stage two and three exercises. There should also be
505 adequate execution and control of energy storage activity. Early in this phase, the amount of
506 hip flexion during exercise may be limited to minimize tendon compression as the higher
507 elastic loading is added. As this is the most provocative stage a conservative approach is
508 recommended with exercises being performed every third day. A stage 1 day would then
509 follow to settle the tendon, with the following day being a strengthening (stage 2- 3) day to
510 form a 3 day high-low-medium tendon load cycle twice a week, with a rest day allowed
511 between cycles.78
512
513 A potential progression of stage 4 exercises may include sprinter leg curl, A-skips, fast sled
514 push or pull, alternate leg split squats, bounding, stair or hill bounding, kettle bell swings
515 (FIGURE 5) and gradual reintroduction of sport-specific squat and lunge activities. For
516 multi-direction sports (e.g. football, rugby) progression should include lateral, rotational or
517 cutting movements to improve strength and control and graduate entheseal loads in multiple
518 planes of movement. Sessions would include a maximum of 3-4 of these activities (typically
519 graduating to 15-20 repetitions or steps, 3 sets) usually starting with one and adding 1-2 per
520 week depending on pain response. The exercises chosen should reflect individual functional
521 and sport demands (e.g. running, sprinting, jumping, lifting etc). For example, Sprinter leg
522 curl is performed open chain with the hip in 80 degrees and knee flexion movement from 130
523 to 20 degrees (see FIGURE 5E) and replicates the running cycle. Hip flexion range and
524 symptom response should be considered during progression.
525
526 These exercise progressions form stepping stones for return to sport, yet it is also important
527 these activities should not be simply added to the normal training volume on resumption, in
528 order to avoid overload and exacerbation of symptoms.95 A graded return to sport can be
529 introduced when the athlete can tolerate the loading requirements of the sport with minimal
530 symptom provocation (i.e.VAS 0 to 3 with pain settling within 24 hours on load tests). Care
531 should be taken with the introduction of hill and speed training sessions, as these can be quite
532 provocative. Team sports may have more complex loading requirements and will require
533 more detailed assessment. A graded return in these cases usually involves gradual exposure
534 to provocative activity in training prior to return to full competition.
535
536 Other considerations
537
538 Dry needling and soft tissue techniques have been utilised in the treatment of PHT but
539 supporting evidence is limited to case series.43, 60, 97 In the authors’ experience, massage and
540 manual therapy addressing tone and restriction in the kinetic chain (e.g. hamstring, tensor
541 fascia latae) can be useful adjuncts in management of PHT. However, such passive
542 interventions are unlikely to improve tissue load capacity, which is a key element of
543 tendinopathy rehabilitation.23
544
545 Anti-inflammatory medication (e.g. ibuprofen) has been suggested for settling irritable
546 tendon pain and may also inhibit tenocyte overstimulation and signalling.93 Whether
547 NSAID’s compromise tendon healing is not fully understood, although ibuprofen
548 administration does not seem to impair normal tendon adaptation in response to resistance
549 training.18
550
551 Other adjuncts that can be considered include extracorporeal shockwave therapy (ESWT) and
552 injections. In the authors’ experience ESWT may modulate pain in less reactive
553 tendinopathies, but is much less effective and can even flare early stage ‘reactive’ symptoms.
554 Cacchio17 reported a superior result with ESWT compared to traditional conservative
555 treatment however the mechanism of effect for ESWT remains unclear.
556
557 Peritendinous corticosteroid injection may provide short term pain relief but symptoms have
558 a tendency to recur.48, 49 Platelet-rich therapies (PRT), autologous blood and other agents may
559 be utilized in longer standing lesions, however there is currently insufficient evidence to
560 support the use of PRT for treating musculoskeletal soft tissue injuries.63
561
562 Surgical treatment of PHT may be an option for recalcitrant cases where symptoms have
563 failed to improve with conservative management. A full description of this approach is
564 beyond the scope of this paper but the reader is directed to a recent review by Lempainen et
565 al.48
566
567 Conclusion
568
569 This narrative review and commentary has highlighted key differential diagnoses, tendon-
570 specific and kinetic chain assessment approaches and intervention strategies for patients
571 presenting with symptomatic PHT. An outline for exercise progression of PHT is proposed,
572 supported by contemporary evidence and principles of tendinopathy management. There are
573 a number of limitations for the recommendations. There is presently a paucity of evidence
574 relating to pathoetiology, biomechanical analyses and clinical approaches relating to PHT as
575 an entity. As there are presently no randomized controlled trials investigating rehabilitation,
576 recommendations in this paper are based on current understanding of tendinopathy patho-
577 etiology as well as hamstring muscle function and rehabilitation principles. These
578 recommendations aim to provide a reference for both clinicians treating PHT and future
579 research into management of this overuse injury. Future research should 1) evaluate the role
580 of hip flexion angle and its effect on tendon compression and pain 2) identify extrinsic and
581 intrinsic risk factors for the development of PHT and 3) study the effectiveness of loading
582 programmes for PHT using validated pain and functional outcome measures.
583
Box1. Differential diagnosis in PHT

 Sciatic nerve irritation at the piriformis muscle or near the ischial
tuberosity
 Ischiofemoral impingement
 Unfused ischial growth plate in a post-adolescent 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 tendon
584
585
586
587
588 FIGURE 1. A) Single leg, bent knee bridge, example of a low load clinical test B) Long
589 lever bridge, example of a moderate load clinical test C) Arabesque, example of a high load
590 clinical test

591
592
593 FIGURE 2. Examples of Stage 1 exercises A) Single leg bridge hold B) Long lever bridge
594 hold C) Straight leg pull down D) Trunk extension
595
596
597 FIGURE 3. Examples of Stage 2 exercises A) Nordic hamstring exercise B) Prone leg curl
598 C) Supine leg curl D) Bridging progressions e.g. Adding weight
599
600
601 FIGURE 4. Examples of Stage 3 exercises A) Romanian Deadlift B) Step ups C) Walking
602 lunges D) Hip thrusts (weights can be added to the bar to increase resistance) E) Single leg
603 deadlift
604
605
606
607 FIGURE 5. Examples of Stage 4 exercises A) Bounding B) Alternate leg split squats C) A-
608 skips D) Cutting E) Sprinter leg curl
609
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1 Proximal Hamstring Tendinopathy: clinical aspects of assessment and

69 management outline presented aims to guide clinicians as well as future research.

71 Key Words; tendon, evaluation, treatment.

107 understanding of pathology and pain in tendinopathy.

114 variation is reported. 34

124 Proximal hamstring tendinopathy is considered to be an insertional tendinopathy and

131 functional activities.

143 sitting is the main load inciting factor.49

154 Hamstring function

156 An understanding of hamstring muscle function is important in PHT rehabilitation. In upright

159 swing, with a second peak reported in early stance.19, 36

171 well as return to sport.8, 90

173 Pathology and pain

182 tendinopathy. Malliaras et al.55 demonstrated an ordinal progression of patellar tendon

191 discussion of potential tendon pain mechanisms.

193 Subjective assessment and screening of other potential pathology

199 ups’ when running) but is worse afterwards.

211 return towards the end of activity

231 of the management of complete and partial proximal hamstring ruptures.

250 Diagnostic tests

260 should increase with load across these tests.

267 have low specificity for diagnosing tendinopathy.24

272 behaviour in diagnosing PHT.

274 Identifying Impairments, Activity Limitations & Participation Restrictions for

275 Determination of Treatment Approach

290 measurement of lumbo-pelvic movement in a clinical setting.80 In principle, a more

293 potential to reduce provocative hamstring load.

301 studied in treatment of PHT.

309 semitendinosus activity with minimal gluteus maximus recruitment.4

321 quadriceps dysfunctions are less common although should be considered.

326 populations that stretch already flexible hamstrings repetitively (yoga).

330 kinetic chain dysfunction is also worthy of mention.

332 Patient-reported outcome measures (PROs)

341 used for within and between session assessment.

362 settle and become stable.

379 normalise load capacity in the entire lower limb.23

387 alongside exercise.

389 Exercise prescription

394 contraction speed and time under tension.1

401 chain factors.

406 variation depending on pain and functional deficits.

410 Resisted isometric exercise in positions without tendon compression is advocated as an

425 gym equipment is limited.

427 Stage 2 – isotonic hamstring load with minimal hip flexion

432 rehabilitation of tendinopathy.83

451 motor control.76

477 presentation and functional goals.

497 ranges should be comfortably achieved with little latent provocation.

499 Stage 4 – energy storage loading

511 between cycles.78

524 symptom response should be considered during progression.

534 to provocative activity in training prior to return to full competition.

536 Other considerations

543 tendinopathy rehabilitation.23

Box1. Differential diagnosis in PHT

590 clinical test

594 hold C) Straight leg pull down D) Trunk extension

598 C) Supine leg curl D) Bridging progressions e.g. Adding weight

608 skips D) Cutting E) Sprinter leg curl

623 Med. 2013;47:1120-1126.

653 Sports Med. 2014;48:448-452.

761 tendon. British journal of sports medicine. 2010;44:944-947.

828 82. Scott A, Backman L, Speed C. Tendinopathy-Update on Pathophysiology. J. Orthop.

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