Ischial Bursitis / Proximal Hamstring Pain

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., the 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. 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.Source: The mechanism of hamstring injuries – a systematic review – PMC (opens in a new tab)

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, giving rise to symptoms.Source: Tendinopathy – PubMed (opens in a new tab)

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, 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.Sources: Hamstring Muscle Injuries: MRI and Ultrasound for Diagnosis and Prognosis – PMC (opens in a new tab); Hamstring Injuries in the Athlete: Diagnosis, Treatment, and Return to Play – PMC (opens in a new tab)

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.

• 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.Source: A systematic review of surgical intervention in the treatment of hamstring tendon ruptures: current evidence on the impact on patient outcomes – PMC (opens in a new tab)
• 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.Source: Extracorporeal Shockwave Therapy for Tendinopathies Around the Hip and Pelvis: A Systematic Review – PMC (opens in a new tab)
• 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 and partial-thickness tears.Sources: Platelet-rich plasma for treatment of chronic proximal hamstring tendinopathy – PubMed (opens in a new tab); Efficacy of platelet-rich plasma in grade 2 hamstring muscle injuries: results from a randomised controlled trial – PubMed (opens in a new tab)