yogabook / pathologie / proximal hamstring tendonipathy

PHT – Proximal Hamstring Tendonipathy: Irritation of the origin of the hamstrings

Definition of

Insertional tendinopathy in the sense of an irritation of the origin of the hamstrings on the ischium. PHT usually occurs as overuse syndrome. It is common in long-distance runners, sprinters and hurdlers, but also in some team sports that require abrupt changes of direction, which demand high power peaks from the muscles, sometimes also in eccentric load impulses. Upright running, i.e. running with little movement and the knee pulled wide towards the chest, also tends to cause PHT due to its large hip flexion angle and the strong negative acceleration required towards the end of the movement. But non-athletes can also be affected. In cross-country running and even more so in sprinting, the phase in which the movement of the front lower leg is delayed in the knee joint and stores energy in the eccentric contraction is considered particularly critical, as the energy storage mainly takes place in the elasticity of the tendons. However, this type of energy storage is essential for a higher level of performance in running and sprinting, as it is primarily efficiency-enhancing. The demands on the hamstrings and its area of origin increase with speed, stride length and (positive) angle of inclination, i.e. when running uphill. It is a disorder with varying degrees of peritendinous inflammation, degeneration and tears. The process usually starts with minor, clinically inapparent damage and increases under repeated stress until it flares up. The relationship between stress (intensity and frequency) and self-healing also plays a role here. Case studies show that in PHT a reduced strength of the hamstrings to knee flexion or hip extension is often detectable, which must be considered as a cofactor of the development. While the strength deficit in the hip extension is more difficult to detect, as the strong gluteus maximus in particular is involved in the movement, the knee flexion can be tested quite well on a leg curl machine, largely in isolation.

he weakness of the gluteus maximus is more difficult to test, but is clearly counted among the favouring factors, as with the same torque to the extension, the hamstrings has to perform more. If the gluteus medius is weak, this can also increase the load on the hamstrings due to improper guidance of the pelvis in the frontal plane. A lack of strength of the synergist adductor magnus as well as disturbances in the distal part of the kinetic chain or the antagonist quadriceps can have a contributory effect.

Since the compression of the origins of the hamstrings can also play a role in the development and maintenance of the disorder, prolonged uninterrupted sitting must be counted among the pain-triggering and aggravating influences, which is clearly supported by empirical evidence. If the option is available, the ischiocrural origin can be relieved by sitting with the pelvis tilted slightly forwards. a commercially available seat wedge is very helpful for this. However, the pelvis tilted backwards must be avoided. Incidentally, compression of the tendons is also considered a cofactor in the development of PHT with frequent very wide flexion in the hip joints and extended knee joints as in a very well-executed uttanasana in very mobile people. However, it should be investigated whether the test subjects concerned may also belong to the group of people who lack adequate ischiocrural and gluteal strength and resilience, simply because their training plan does not include such units. Apart from this, body size and proportions may also play a certain role.

The insertion of the semimembranosus is more frequently affected than the joint insertion of the biceps (caput longum) with the semitendinosus. In rare cases, the origin of the pars ischiocondylaris of the adductor magnus, which lies even lower (more caudal) on the ischium, is also affected, as this part also has a hip extending function and thus is affected by the triggering activities and circumstances. Then not only straight forward bends such as uttanasana and externally rotated–abducted hip flexion such as trikonasana trigger the familiar pain, but also wide abductions. This can go so far that even with a very flexible ischiocrural group, in which an upright upavista konasana does not yet represent any stretching of the hamstrings, from a certain abduction angle, the familiar pain is triggered, which decreases noticeably with a reduction in hip flexion. Then poses such as baddha konasana can also trigger the pain. Terminologically, if the origin of the adductor magnus is also affected, this would be referred to as an additional PAMT.

The thickness, fibrousness and poor blood supply of the tendinous attachment to the bone make healing more difficult. Pain-inducing activities lead to maintenance of the irritation.
With increasing severity of PHT, everyday movements such as climbing stairs with a skipped step, normal stair climbing, faster walking or even slow walking can already trigger the pain.

The triggers primarily include all types of hip flexion, the higher the static or dynamic load and the lower the flexion angle in the knee joint. However, if more pronounced, also short-range hip extensions around anatomical standard pose like walking.

The hamstrings have three tasks during running (to a much lesser extent, this applies similarly to walking ):

1. Delaying knee extension through an eccentric contraction, starting approximately when the knee flexion falls below 30°. This delay protects the knee joint from hyperextension, the hamstrings from strain and directs the kinetic energy of the lower leg proximally.
2. Significant contribution to hip extension, which mainly generates propulsion
3. Support of the gastrocnemius during flexion of the knee joint

Several etiologic factors are discussed:

1. Shear forces between base and ischium
2. Compression of the affected area
3. Displacement of the tendon area by the ischium during wide flexion

PHT therapy is generally purely movement-orientated and involves strictly avoiding the related pain (except for rehabilitative training, see below) and, above all, regular strengthening. Depending on the severity and exercise therapy efforts, the disorder can last 6 to even over 12 months.

Cause

1. Relative overload and inadequate training staging
2. Preliminary damage
3. Excessive or insufficiently warmed up release movements such as lunges, uphill running, sprints
4. High power demand on the hamstrings in wide flexion in the hip joint
5. Intensive stretching of the hamstrings in wide flexion in the hip joint with the knee joint (approximately or fully) extended as in yoga, Pilates, etc.
6. Prolonged sitting can worsen the situation (supply situation, shortening)
7. Training in an already fatigued state

Predisposing

– Behavior

1. Training or material deficiencies
2. adverse environmental conditions such as cold, humidity

– Musculoskeletal system

1. Misalignments
2. Leg length differences
3. Muscular imbalances
4. Reduced flexibility, especially but not only of the hamstrings
5. Weakness of the ligamentous apparatus resulting in loose joint guidance
6. Proprioceptive deficits
7. ischial tuberosities already painful by pressure
8. Weaknesses in other areas of the musculoskeletal system that are relevant to the movement sequence, e.g. the core when running
9. Dysfunction of the pelvis (incl. SI joint)
10. Known or unknown previous damage to relevant areas
11. Weak muscles that are inadequate for the load
12. Lack of longitudinal muscle adaptation

– Other factors

1. Female gender
2. Age: loss of muscle mass and strength, degeneration of tendons
3. Overweight

Symptoms

1. Profound pain on movement and above all on exertion, radiating a few centimeters from the ischium along the hamstrings, which depends on the level of exertion, but above all on the geometry (wide flexion in the hip joint with the knee joint more or less extended) (more likely to occur near the extension of the knee joint ).
2. Painful pressure in the area
3. Triggered and worsened by running, sprinting, (deeper) squats, lunges, wide forward bends
4. Usually gradual progression
5. Pain-inducing stress worsens
6. Possible deterioration due to prolonged sitting

Therapy

1. Avoidance of triggering and maintaining factors, in particular painful angles in forward bends and painfully high loads
2. Regenerative strength training only until before the pain is triggered, with smaller to medium loads and a higher number of repetitions
3. Maintaining and promoting flexibility
4. Identification and elimination of predisposing factors

NHK

Asana practice

Please refer to the explanation in the FAQ.

Asanas

In addition to various postures that strengthen the hamstrings as extensors of the hip joint in at least medium sarcomere length, such as

1. utkatasana
2. right-angled uttanasana
3. Right-angled shoulder stand
4. Right-angled headstand
5. Warrior 3 pose
6. Warrior 1 pose

and other comparable postures, in all of which care must be taken to ensure that the pain is not triggered, postures in which pain is unlikely to be triggered due to the short sarcomere length are of course also suitable. These include

1. purvottanasana in all variations, especially those with outstretched legs or with one leg raised, where care must be taken not to trigger the pain
2. setu bandha sarvangasana
3. eka pada setu bandha sarvangasana lower leg. Be careful with the raised leg!
4. urdhva dhanurasana
5. eka pada urdhva dhanurasana lower leg. Be careful with the raised leg!
6. salabhasana

Correctly performed strengthening postures from sports such as

1. Squats with and without weight
2. Deadlift, again: only up to the point of pain; to make it easier, the knee joints can be bent a little
3. Hyperextensions, even just before the pain is triggered
4. Leg biceps curls on the machine

In addition to the above mentioned exercises there are some more which can be recommended, which can be carried out under the above conditions up to NRS 3:

• single leg bridge (corresponds approximately to taking an eka pada setu bandha sarvangasana with the leg raised in advance)
• prone hip extension (corresponds approximately to the one-sided leg part of salabhasana)
• prone leg curl (a machine exercise in which one or both knee joints are bent against the resistance of the machine while lying prone on a bent table for slight hip flexion.
• nordic hamstring curls (movement of the whole body with extended hip joints relative to fixed lower legs)
• bridging progressions (dynamically repeated setu bandha sarvangasana)
• supine leg curl (one-legged knee flexion and –extension with the shoulder resting on the floor and the foot on a rolling board)
• lunge
• arabesque (dynamically repeated standing balance similar to warrior stance 3, but with slightly bent standing leg), also called „diver“
• hip thrusts (hip extensions with the upper body elevated and feet on the floor)
• one-legged deadlifts
• sled push or pull (push or pull weighted sledges)

The following rule applies to all poses and exercises for rehabilitative training: the movements or poses should not be performed quickly or even energetically, but rather a little longer in order to achieve a useful TUT. The pain should not be triggered at all or at most be as severe as NRS 3, and then on condition that a) the pain subsides completely within 24 hours of the exercise and b) the pain during the exercise does not increase over the sequence of exercise units.

Once the structures have been significantly strengthened and the irritation causing the pain has healed, the lost flexibility can be restored all the more safely. Another supportive measure is activities such as brisk walking, preferably uphill, and climbing stairs, provided that they do not trigger the pain or are modified or parameterized in such a way that they do not trigger it. Of course, they stiffen the back of the leg, but they promote healing and strengthen the structures. Running with faster passages should also have a positive effect. However, all jerky movements should be avoided, as should all activities that trigger the pain, including intensive stretching!