Ischial bursitis / Proximal hamstring pain
Insertional hamstring pain is a problem for athletes but also the ageing general population. It is associated with long-standing localised buttock pain that can be refractory to treatment and can have a profound effect on both function and quality of life for patients of all ages. The proximal hamstring anatomy is complex. Simplistically there is a lateral attachment of the semimembranosus onto the ischial tuberosity; the conjoint attachment of the semitendinosus and biceps femoris has more of a superior and intermediate attachment with the adductor magnus attachment along the most medial aspect. Anatomical Relationships of the Proximal Attachment of the Hamstring Muscles with Neighboring Structures: From Ultrasound, Anatomical and Histological Findings to Clinical Implications – PMC
The differential diagnosis is extensive including tendinosis of the conjoint tendons and semimembranosus tendon, Partial and complete tears at both the myotendinous junction and enthesis (tendon attachment) with or without bony avulsion, adductor magnus pathology and ischial bursitis. Proximal Hamstring Tendinopathy: A Systematic Review of Interventions – PubMed.
A further condition referred to as ‘deep gluteal pain syndrome’ encompasses a further classification of buttock pain which includes ischiofemoral impingement and piriformis syndrome, which are potential causes of non-discogenic compression of the sciatic +/- pudendal nerve. This patient information context will not be directly referring to these conditions, but more information can be found here if of specific interest. Deep gluteal syndrome as a cause of posterior hip pain and sciatica-like pain – PubMed
What are the signs and symptoms?
Classifications are typically broken into traumatic and atraumatic causes. Traumatic injuries are generally reserved for the young, high-demand athlete but can also develop in the more sedentary older patient who partakes in an unfamiliar explosive exercise (e.g., Fathers race on their child’s sports day). The mechanism of injury is the same in both cohorts, with failure of the proximal enthesis or myotendinous unit due to high-velocity end-of-range hip flexion with an extended knee. The mechanism of hamstring injuries – a systematic review – PMC. Symptoms are abrupt with an inability to continue to play/run. Depending on the severity of the injury and location, there is likely to be bruising due to localised haemorrhage that typically becomes apparent over the following 24 hours.
In the elderly patient there is more of an insidious onset with localised pain at the ischial tuberosity generally provoked with extended periods of sitting due to localised compression. This cohort of patients tends to have degenerative tendons due to microtrauma that incites tissue degradation and disorganisation of the collagen fibres with an increase in the microvascular and sensory nerve innervation Tendinopathy – PubMed giving rise to symptoms.
How is it diagnosed?
Ultrasound and MRI are the mainstay of investigation, especially in the athlete population, when determining return to play (RTP) protocols. Both have their strengths and limitations in assessing the proximal hamstring complex. Needless to say, the clinical examination and knowledge of the mechanism of injury are also vitally important information.
For athletes the most appropriate immediate imaging is MRI, as it allows, in most cases, a precise prognosis of the RTP time. This is because MRI can accurately define whether the injury has a great tendon affection, if it has musculotendinous involvement or if it is ‘purely’ a muscle injury. Hamstring Muscle Injuries: MRI and Ultrasound for Diagnosis and Prognosis – PMC With each having a different RTP prognosis and a different progression of rehabilitation. Ultrasound is sensitive at assessing for musculotendinous junction injuries and muscle belly injuries but less accurate in assessing the tendon enthesis (attachment) and for avulsion injuries. Hamstring Injuries in the Athlete: Diagnosis, Treatment, and Return to Play – PMC.
For the general population, imaging is not needed to make the diagnosis of an acute hamstring strain unless there is concern of avulsion injury. Similarly, in older patients with an insidious onset, imaging is usually reserved for refractory cases that may help guide intervention.
How are they treated?
- In traumatic proximal hamstring injuries, a period of unloading and progressive rehab is the mainstay of treatment, usually guided by the medical team the athlete is under. RTP protocols will be guided by the classification of the injury, with time varying from a couple of weeks for simple muscle belly injuries up to 6-9 months for tendon injuries. Surgery may be indicated in these patients with complete tendon detachments or avulsion injuries, with early surgical repair leading to better functional outcomes. A systematic review of surgical intervention in the treatment of hamstring tendon ruptures: current evidence on the impact on patient outcomes – PMC
- In non-traumatic cases physiotherapy is appropriate to improve tendon capacity and tolerance. Shockwave therapy is an adjunct which can be helpful for chronic tendon issues around the hip. Extracorporeal Shockwave Therapy for Tendinopathies Around the Hip and Pelvis: A Systematic Review – PMC
- Ultrasound-guided steroid and local anaesthetic injection into the ischial bursa is a further conservative option that can be helpful in carefully selected patients.
- An ultrasound-guided PRP injection into the proximal hamstring tendon is a treatment option in refractory cases that can be helpful for both tendinosis Platelet-rich plasma for treatment of chronic proximal hamstring tendinopathy – PubMed and partial-thickness tears Efficacy of platelet-rich plasma in grade 2 hamstring muscle injuries: results from a randomized controlled trial – PubMed
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