Hamstring Tendonitis

What is the hamstring tendon?

The hamstring tendons are the rubbery, not-so-soft rope-like structures you feel when you touch the back of your thighs.

The hamstring tendons are the bands of soft tissues that connect the hamstring group of muscles to your bones- the pelvis, the tibia-fibula (the shin bones) and the knee, allowing the knee joint to bend and extend.

Anatomy of the hamstrings 

The hamstring group is a two-joint muscle group since it crosses two joints- the hip and knee joints.

the hamstring group consists of three muscles- the semimembranosus, the semitendinosus and the biceps femoris (long and short heads) originate from the ischial tuberosity of the pelvis except for the short head of the biceps femoris.

The short head of the biceps femoris originates from the distal femur (thigh bone.)¹

The semimembranosus and the semitendinosus originate from the medial aspect of the femur and insert into the medial aspects of the knee joint and act as a primary contributors to knee stability.

The semitendinosus joints with gracilis and the sartorius muscles form pes anserine at the medial aspect of the tibia (the shin bone.)

‘itis’ – inflammation. Hamstring tendonitis is an inflammation that occurs due to overuse or repetitive stress in the tendon of the hamstring group of muscles and is often characterized by pain at the back of the thigh.²

Hamstring tendons can carry the load placed upon the muscles during random situations but overloading the tendon generates more collagen fibres resulting in the thickening of the tendons and hence the flexibility is lost.

Is Tendinitis the same as tendonitis? 

Yes, tendinitis can also be referred to as tendonitis, as both involve inflammation of the tendons and presents the same signs and symptoms.

 Pes anserine bursitis, also known as Voshell’s bursitis, is characterized by pain in the medial aspect of the knee joint. The tenderness of the inflammation usually occurs at the medial side of the knee joint.

Bursa is a sac-like cavity structure that acts as a cushion and eases the movement of the joint.

Pes anserine bursa is located between the medial side of the tibia (shin bone) and the three tendons of the hamstring muscles and the inflammation of the bursa are the pes anserine bursitis which is accompanied by pain and swelling in the medial side of the knee joint.³

Pes anserinus bursitis and hamstring tendonitis are often misinterpreted because both occur concurrently as the tendon underlying the bursa gets inflamed.

Signs are

• Restrictions to performing knee movements freely
• Mild to moderate spasms
• Swelling
• Presence of tenderness

The Symptoms

• Hamstring injuries are most commonly seen in athletes who are into running, kicking and other ballistic exercises
• You might feel a sudden onset of pain at the back of your knee
• Inability to put much pressure on your knees and difficulty in walking
• Dull pain in your ‘sitting bones’ causes major discomfort in your daily activities
• You might feel some amount of tightness at the back of your thigh
• Tingling sensations that radiate down your lower leg
• In severe cases, the patient complains of losing balance and falling to the ground
• Causes and Risk Factors The most common cause of hamstring tendonitis is inadequate flexibility and imbalance of the strength of the muscles (hamstring and the quadriceps)
• Overuse as seen in sports activities makes the tendon incapable to bear the load
• Poor posture while sitting
• Excess training with heavy weight

You are at a risk to develop hamstring tendonitis if you

• Have an imbalance between your quadriceps and your hamstrings
• Have deconditioned hamstring muscles
• If you forget to do your warm-ups and cool-downs before your practice
• Had a history of knee injuries

When to see a doctor

Its time to visit your doctor when you

• Have severe pain at the back of your thigh that radiates throughout the whole leg
• Cannot walk or sit
• Find it difficult to perform daily chores
• Feel the loss of sensation in your buttock areas
• Start limping and feel like losing balance and falling to the ground

Diagnosis

• During your visit, your doctor or your physical therapist will assess you both subjectively and objectively to rule out the main cause
• You need to be very vocal about your history, and chief complaints for proper clarity
• X-ray images are of less value unless it’s a case of fracture or avulsions
• But in case of severe pain or discomfort, your doctor might ask for a CT scan or MRI or Ultrasound

You can self-assess at home in the following ways:

• Lie on your tummy, bend your knees to around 90 degrees and slowly straighten your knees. If this bending reproduces the pain, you might have hamstring tendonitis
• Lie on your back, do a straight leg rise to 90 degrees, pull your knees to your chest and straighten your legs. The pain while this movement might be due to hamstring tendonitis

Treatment

Surgical

In most cases, hamstring tendonitis heals by itself if proper care is taken, usually taking around 2 weeks to heal.

If your pain is highly debilitating and making your life worse and on diagnosis, the doctor finds out a high degree of tendon tear, you might need to undergo a surgical procedure.

Non-surgical

1. Conservatively, the R.I.C.E Protocol is helpful

Rest- In acute injuries, resting the affected leg, avoiding any strenuous activities that require knee bending, jumping, etc

Icing- Icing is a great way to reduce swelling since cold compression reduces the blood flow to the affected area. Put a cold pack inside a plastic bag and wrap it around the back of your thigh for 15 mins and take a breath of relief. Repeat this thrice a day.

Compression and Elevation- compressing the affected limb and elevating the leg by keeping the leg over a pillow (above the level of your heart) helps decrease the blood flow.

1. NSAIDS (Non-steroidal Anti-inflammatory Drugs) also known as painkillers
2. Care must be taken not to bend your knees in any way
   • Physical therapy – physical therapy plays a very important role in the treatment of knee injuries
   • The use of ultrasound therapy and TENS (transcutaneous electrical stimulation) on the affected area helps in reducing pain and aids the healing process
   • Electrotherapy sometimes offers a placebo effect
   • Manual therapy- neural mobilization and stretching exercises help in healing non-surgically

Exercises

Initially, any major physical exercises are to be avoided till the pain and the swelling subside.

However, gentle and slow movement is encouraged.

1. Isometric knee flexion- Put a roll of a towel under your heel and sit on your bed
   • Slightly bend your knee
   • Gently press the towel against the bed kept under your heel
   • Hold for 10 secs and then release
   • Repeat this exercise 10 times

1. Straight leg raise- Lie on your back
   • Gently lift one leg, and hold
   • Relax and lower your leg down. Do this on both legs
   • Care should be taken to limit the load to the injured muscle to avoid re-injury

NOTE: all these exercises must be performed in a pain-free range.

With improvement in pain, after the first week, the exercises should progress from isometric to an advanced level with proper care.

1. Pelvic bridging- lie on your back
   • Bend your knees and keep your feet flat on the bed.
   • Slowly lift your hip and hold for 5 seconds, relax and lower your hip down
   • Repeat this exercise 10 times

• Hamstring stretching- lie on your back
  • straighten your leg and lift it
  • Wrap a long towel or a belt around your feet and gently pull the belt in an upward direction Hold there for a few seconds

• Relax and repeat

• Squatting- you can switch to squatting when knee bending is out of discomfort
  • Wall squatting is a good way to start
  • Stand against a wall, gently bend your knees and lower your body down (the way you sit on a chair)
  • Don’t sit all the way done, bending your knees to the maximum
  • Slowly, switch to squatting without a wall

NOTE: all these exercises must be performed in a pain-free range.

Recovery and outlook

People with hamstring tendonitis recover within a week or two. The outlook is positive in this.

However, during this period, along with R.I.C.E, care should be taken not to re-injure the muscle.

Tendonitis usually turns chronic and to prevent this, don’t overlook any signs and symptoms.

The early visit to the doctor will help in quick healing and further complications could be avoided.

Conclusion

Hamstring tendonitis is a painful condition felt at the back of the thigh yet it can be treatable in major cases, if not delayed.

It occurs more commonly in athletes and has a high chance of recurrence. Rehabilitation includes assessment of the muscular deficits, neuromuscular control, flexibility, and core muscles stability, eccentric training has shown to be important for an athlete to return to sports.⁴