Tuesday, 31 July 2012

Hamstring Tendinopathy: A case of long-term management

A Case Study

A 30 year old female with a history of hamstring tendinopathy spoke to me at length yesterday about her hamstring tendinopathy (I have been a part of the process along the course of treatment) and explained her treatment and investigation over a course of 17 months (and still continuing).

In April (2011) during a standard 20km long run our subject feels pain in her left hamstring that is quite localised, however it does not stop her completing her long run. Later that week the hamstring pain progresses to a point where she could not run.

Initially she rests for a week and attempts another run only to have the pain return more severely and to a point where she must walk home. A further month is taken off from running and no other treatment is sought. It becomes obvious to her this is longer term and treatment will be needed. She is unable to run and wakes with morning pain and stiffness.

In June of last year she saw a soft tissue therapist who found her left glute med wasn’t functioning properly (poor timing), her TFL was overloaded and her iliopsoas (hip flexors) were also doing a lot of work. She was unable to activate her hamstring on a ‘bridge’ * assessment. Treatment to the above areas improved her bridge and glute timing and pain, but only temporarily.

Fig 1. The hamstring functions eccentrically on and just before heel strike. Large loads are place through the hamstring complex. If the hamstring experiences pain and/or dysfunction load will be place through the tendon and not taken up by the muscle itself

A moderate, controlled eccentric program was trialled for the hamstring, increasing weight weekly and tolerating pain. After 8 weeks there was no improvement.

In August of last year, a referral to a sports doctor found, through ultrasound some thinning of her tendon (though this was bilateral – could this just be ‘her anatomy?’ Does this predispose her?). Cortisone was injected into the tendon without guidance. There was no change in her pain and she was still unable to run.

In November (3 months after the first cortisone injection) she paid a second visit to the sports doctor where an MRI was performed on her lumbar spine for possible referral. This reveals a perfect spine for a healthy 31 yr old. She is recommended chiropractic intensive treatment, consisting of twice per week treatment for 8 weeks. On cessation her back felt great however her hamstring pain had no change.

A second opinion was sought in March of this year (2012) where a referral for another ultrasound was made, finding extensive degeneration about the hamstring tendon and thickening between the tendon and the surrounding paratendon. An ultrasound-guided cortisone injection with saline was injected into the paratendon space in an effort to ‘debride’ the surrounding tissue.

Fig 2. Tendinopathy usually occurs in the attachment of the long head biceps femoris. The junction between the muscle and tendon is also a weak spot (MTJ) leading to degenerative tears. 

At the same time an appointment was made to see a physiotherapist with experience in this area. He initially provided low-level glute strengthening and hydrotherapy.

There is a plan to start some progressive overload eccentric training as we speak. Eighteen months down the track this is still long and ongoing and with no certainty with outcome.

There are numerous clinical cases in the distance runner where hamstring tendinopathy is long and drawn out. This is one injury that needs to be addressed as soon it appears. As tendon research and understanding improve over the years, so should our clinical outcomes.

For now,