Understanding

UNDERSTANDING TENDINOPATHIES OF THE HIP & PELVIS BOOK THREE: Proximal Hamstring Tendinopathy Introduction Tendinopathies of the hip and pelvis represent a large burden on both the sporting and ageing populations. Growing evidence is shaping contemporary conservative management of tendinopathy. This e-book series aims to provide readers with guidance towards a deeper understanding of tendinopathies of the hip and pelvis and more effective clinical management based on an emerging evidence base derived from scientific studies on structure and mechanobiological mechanisms, risk factors, impairments and the available information on effects of intervention. Book 3 of this series details mechanobiological mechanisms of proximal hamstring tendinopathy and the clinical implications for assessment and management of this condition, common particularly in the running population. Local structural and functional anatomy, together with known patho-anatomy is examined prior to discussion of the pathoaetiological model. This model and evidence regarding impairments is reviewed and together these elements provide a basis for contemporary assessment and management of proximal hamstring tendinopathy. Available evidence from the scientific literature is combined with over 25 years of clinical experience to provide a wealth of information for immediate use within a clinical environment. Is this e-book suitable for you? This book is suitable for anyone involved For more information in management of tendinopathies of the hip and pelvis or prescription of email info@dralisongrimaldi.com.au exercise in at-risk groups – such as the phone (07) 3342 4284 athletic population or perimenopausal web dralisongrimaldi.com women. The content assumes readers have a basic knowledge of anatomy and muscle function in this region. PAGE 2 OF 50 Copyright Alison Grimaldi 2018 BOOK CONTENTS Chapter 1 IMPACT AND PREVALENCE ............................................. 4 Chapter 2 CLINICAL PRESENTATION ................................................ 6 Chapter 3 REVIEW OF LOCAL ANATOMY .......................................... 10 Chapter 4 PATHOLOGY & TERMINOLOGY ......................................... 16 Chapter 5 PATHO-AETIOLOGY ....................................................... 20 Chapter 6 IMPAIRMENTS ............................................................. 24 Chapter 7 DIAGNOSIS .................................................................. 26 Chapter 8 MANAGEMENT ............................................................. 33 REFERENCE LIST .......................................................... 46 Copyright Alison Grimaldi 2018 PAGE 3 OF 50 CHAPTER ONE IMPACT & PREVALENCE PREVALENCE Athletes Sedentary population IMPACT Sports participation & performance Employment PAGE 4 OF 50 Copyright Alison Grimaldi 2018 The Impact & Prevalence of Proximal Hamstring Tendinopathy The impact of proximal hamstring tendinopathy Limited evidence exists regarding the impact and can be substantial for athletes, most unable to prevalence of proximal hamstring tendinopathy. train or compete effectively (Nicholson et al. Information available is from surgical or small 2016, Puranen & Oravo 1988). As the condition conservative rehabilitation case series, rather often becomes chronic, it may have longer term than large population based prevalence studies. impacts on participation and performance and Proximal hamstring tendinopathy presents most for elite athletes has the potential to end their commonly in athletes, particularly those involved professional career. Even for the recreational in middle and long distance running or sports runner, interference with their normal running involving running such as triathlon, heptathlon, schedule can have secondary impacts on decathlon (Fredericson 2005, Lempainen et al. general health, mental health and quality of life. 2009, White 2011). While for many athletes the main impact is on Proximal hamstring tendinopathy may also their sporting activities, for some and certainly present in athletes competing in field sports for the non-athletic population the primary such as the various football codes, ice hockey impact is on their ability to sit comfortably. This and baseball and sports involving jumping and can become a major issue, with consequences landing such as long and triple jump and ballet for those in occupations that are primarily (Lempainen et al 2009). In these sports, high performed in sitting at a desk or in a motor ranges of hip flexion are regularly used, often vehicle. at speed and/or under load, placing high loads on the hamstring complex. This condition may also present however in the older, non athletic population who spend more prolonged periods sitting (de Jesus et al. 2015, Puranen & Oravo 1988). In clinical practice, presentations in older individuals often involve co-morbidities. From a mechanical perspective, there may be some form of co- existing functional limitation down the kinetic chain (knee or ankle). Co-presentation of gluteal and proximal hamstring tendinopathy is also not uncommon in post-menopausal females. They often present with a diagnosis of gluteal tendinopathy or ‘trochanteric bursitis’, but also have ischial pain and signs consistent with proximal hamstring tendinopathy that has gone undiagnosed. Copyright Alison Grimaldi 2018 PAGE 5 OF 50 CHAPTER TWO CLINICAL PRESENTATION AREA & NATURE OF PAIN PAINFUL POSTURES & ACTIVITIES HISTORY OF SYMPTOM ONSET PAGE 6 OF 50 Copyright Alison Grimaldi 2018 Area & Nature of Pain Proximal hamstring tendinopathy is recognised as pain in the immediate vicinity of the ischium, that may extend to the mid- posterior thigh. (Fredericson 2005, Lempainen et al. 2009, 2015, Nicholson et al. 2016) The pain associated with an isolated hamstring tendinopathy is generally described as a deep ache, does not usually refer to or below the knee, and peripheral neurological signs and symptoms are absent (Lempainen et al. 2009, 2015). In some sufferers however, the adjacent sciatic nerve becomes involved secondarily, tethered within fibrotic adhesions (Fredericson 2005). In these cases the patient may complain of symptoms of sciatica with pain extending more distally, sometimes sudden and stabbing or burning in nature. Parasthesia in the distribution of the sciatic nerve may also be reported. This complication has been referred to as ‘ Proximal Hamstring Tendinopathy-related Sciatic Nerve Entrapment’ (Mattiussi & Moreno 2016). Copyright Alison Grimaldi 2018 PAGE 7 OF 50 Painful Postures & Activities Prolonged sitting and driving are problematic, and sitting on a hard surface is much more painful. Patients often offload their buttock by side shifting their trunk and lifting their ischium off the chair, sitting with their buttock half off the chair, or with their hands under their proximal thighs. You might notice the patient offloading in these ways during their patient interview, or they may prefer to stand while you discuss the problem. Other aggravating activities include walking upstairs or uphills, squatting/deadlifting and lunging (worst if deep or if trunk is inclined forward), and forward lean activities such as putting something in the bin, loading the dishwasher, weeding the garden from a standing position. Golfers may report pain when leaning over to place their ball on the tee or when climbing out of a bunker. Running athletes may experience most difficulty when running uphill or at higher speeds where stride length and loads increase. Particularly with milder presentations, the pain may ease as the patient runs but worsen on cooling. As the condition progresses, pain may be evident throughout their whole run and impact on their gait pattern. Runners frequently report they are no longer able to stride out, feeling like their hamstrings are short and unable to lengthen during late swing phase. PAGE 8 OF 50 Copyright Alison Grimaldi 2018 History of Pain Onset Taking a careful history to identify any loading Most commonly, the pain of proximal hamstring errors will be critical tendinopathy develops gradually or insidiously. However, for some the onset is rapid, usually for both recovery induced by some sudden strain or stretch across the hamstring complex (Lempainen et and prevention of al. 2009, Puranen & Oravo 1988, Cacchio et recurrence in the al. 2011). Onset of lower buttock pain of high intensity following a sudden hamstring strain longer term. raises suspicion of a partial or full thickness tendon tear. Full proximal hamstring origin avulsion may occur with an eccentric hamstring load during forceful hip flexion with the knee extended. An audible pop is usually heard with a full rupture, and substantial bruising is common, tracking down towards the knee. Common mechanisms include a slip into the front splits position, waterskiing and martial arts (Chahal et al. 2012). Questioning the active patient about recent change in loading patterns is useful. A common clinical presentation is the patient who has increased their hill walking/running or speed sessions leading up to an event, often leaving inadequate recovery time between sessions. They may have joined a walking or running group that includes lots of hillwork to which they are unaccustomed. Joining group training classes that involve dynamic deep split lunges, stair bounding, burpees or kettlebell swings might initiate symptoms, particularly in an older individual who may have some pre-existing degenerative tendon change. Copyright Alison Grimaldi 2018 PAGE 9 OF 50 CHAPTER THREE REVIEW OF LOCAL ANATOMY

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