A common & often overlooked cause of proximal thigh pain is hamstring origin tendinopathy. It has been described as an “important cause of chronic pain in the active population.” (1). It is common in runners, hockey players, lawn bowls, football players, and hurdlers. It is also prevalent in sedentary individuals who sit most of the day. It is known to be more common in peri-menopausal females, where the presentation may be bilateral.
Pathology
Tendinopathy occurs due to areas of compression between the undersurface of the tendon & the bone interface. The biceps femoris & semimembranosus are the tendons most affected. At the cellular level, there will be increased cellularity, ground substance accumulation, collagen disorganization, & neurovascular ingrowth. There will sometimes be involvement of the ischiogluteal bursa. As with most tendinopathies, it is likely that chronic disease will make the hamstring origin prone to partial tearing or avulsion injuries. Proximal hamstring rupture is discussed at:
Presentation
There is usually deep buttock soreness localised over the ischial tuberosity. There will often be associated aching into the hamstring, due either to secondary muscle tension or sciatic nerve irritation. In chronic cases sciatic-related symptoms may include paraesthesia in the posterior thigh. The pain is often aggravated by walking, stretching, running, squatting, lunging and sitting. Hard chairs become very uncomfortable. The pain will often improve during activity when the tissues are warm, but be worse on cool-down. Post-activity exacerbation may last several hours to a few days. Sometimes pain initially improves but worsens toward the end of activity.
Palpation findings may be inconclusive, as it can be difficult to find a specific area of tenderness. Functional testing may provide better information, simulating activities that both increase tendon compressive loading & symptoms. Neurodynamic tests may be positive for sciatic nerve involvement.
Differential diagnosis
Other causes to consider include lumbar spine or SIJ referral, lumbar radiculopathy, proximal hamstring tear, and piriformis syndrome. Less likely is hip joint referral.
Contributing factors
Possible contributing factors include training errors, poor running or walking gait, prolonged sitting, gluteal or hamstring muscle weakness, tightness in the hip flexors or hamstrings, excessive hill running, postural factors including anterior pelvic tilt, restricted hip extension range, poor lumbo-pelvic control, over-stretching, and heavy weight training. Intrinsic factors include older age, increased BMI, certain metabolic causes including diabetes, and hormonal factors.
References:
1. Brukner, P & Khan, K (2012). Clinical Sports Medicine, 4th ed. McGraw Hill.
2. Malliaras, P & Purdam, C (2014). Proximal hamstring tendinopathy assessment & management. Sport Health, 32, 1, 21-29.
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