Proximal ( or High) Hamstring tendonopathy

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jpgibson
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Proximal ( or High) Hamstring tendonopathy

Postby jpgibson » Mon Feb 26, 2018 9:54 pm

Been putting up with this for 3 months now. Although Ive taken up going to the gym, I cant ride. Even a trip round the block ( 3 km) stirs it up. Not painful ( like it was), but annoying and pretty easily aggravated.
Anyone had any experience with this? Might be time to hang up the bike......

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ValleyForge
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Re: Proximal ( or High) Hamstring tendonopathy

Postby ValleyForge » Mon Feb 26, 2018 10:18 pm

It's a pretty recently described pattern of injury. How was yours diagnosed?
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jpgibson
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Re: Proximal ( or High) Hamstring tendonopathy

Postby jpgibson » Tue Feb 27, 2018 8:38 am

Clinically by a sports med physio, and then by MRI ( which was reported as a mild grade). Considering a prp injection as its been 3 months and I'm starting to get a bit frustrated by it!

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ValleyForge
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Re: Proximal ( or High) Hamstring tendonopathy

Postby ValleyForge » Tue Feb 27, 2018 8:52 am

jpgibson wrote:Clinically by a sports med physio, and then by MRI ( which was reported as a mild grade). Considering a prp injection as its been 3 months and I'm starting to get a bit frustrated by it!

Good that you had the diagnosis backed up by an MRI. SMT is a "trendy" diagnosis and - if you have a new hammer, everything looks like a nail.
It's part of the group of "enthesopathies" and they have a very slow repair course. Three months is still very early - perhaps stick with the treatments that have been shown to make a difference. Long-acting NSAIDs produce a moderate improvement; moderation of exercise to avoid sudden loading (weights, circuits et al) and stopping smoking if you do are the interventions that have evidence behind them too. PRP, hGH analogues, cortisone, focussed ultrasound, infrared and hyperbaric oxygen have all been trialled. And by that you can tell the results are pretty patchy.

Six to 12 months is the repair cycle you are looking at.
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jpgibson
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Re: Proximal ( or High) Hamstring tendonopathy

Postby jpgibson » Tue Feb 27, 2018 9:23 am

Thanks so much! I'm just really impatient and want an instant fix. It nearly gets better then I do something that stirs it up ( bit).I'm much better than I was ( when to bend over would result in an 'ouch' ( or words to that effect!). I'm doing eccentric exercises ( my own interpretation with hamstring curls), which seem to help. Looks like I'll be careful and try to be patient. I suppose I shouldnt really complain as I can work, ride my motorbikes and go to the gym. It's really just cycling that might have to be retired.....
I'm nearly 52, so that might have something to do with it too!

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ValleyForge
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Re: Proximal ( or High) Hamstring tendonopathy

Postby ValleyForge » Tue Feb 27, 2018 9:43 am

jpgibson wrote:Thanks so much! I'm just really impatient and want an instant fix. It nearly gets better then I do something that stirs it up ( bit).I'm much better than I was ( when to bend over would result in an 'ouch' ( or words to that effect!). I'm doing eccentric exercises ( my own interpretation with hamstring curls), which seem to help. Looks like I'll be careful and try to be patient. I suppose I shouldnt really complain as I can work, ride my motorbikes and go to the gym. It's really just cycling that might have to be retired.....
I'm nearly 52, so that might have something to do with it too!

Generally repeated stressing of the affected tendon with exercise is recommended against. It is the repeated full loading and unloading of the tendon that seems to perpetuate the inflammation. Hamstring curls would not be helping in all likelihood.
It is absolutely classical to observe a cyclic pattern in these. Recovery is followed by return to activities and a flare-up. Then the cycle repeats. It might be best to look to non-intensive cycling, changing your bike fit to unload your hamstrings, aviod sprints & hills.
Another classical observation is the pain follows by several hours the exercise that triggers the inflammation. So evening & nocturnal symptoms are common.
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jpgibson
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Re: Proximal ( or High) Hamstring tendonopathy

Postby jpgibson » Wed Feb 28, 2018 5:23 am

Thanks once again! The physio started me on hamstring bridges, 'fast up slow down', I'm using the hamstring curl machine thingy to replicate those. I seem to know what amount I can and cant do.Obviously sitting for long periods isnt great ( example: last week I rode my motorbike to work for 4 days, had a short (3km) pushie ride- it stirred it up a bit). Based on what Ive looked at in terms of exercises that work, the hamstring curls I'm doing are replicating eccentric exercises.
I think cycling might be out as it seems load AND compression on the tendon are the culprits, and a bike saddle seems to be optimally placed to compress the origin of the tendon.
Appreciate your help.Jonathan

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Re: Proximal ( or High) Hamstring tendonopathy

Postby jpgibson » Fri Mar 02, 2018 7:45 pm

Yep , worse again.I suspect too high a weight on the prone hamstring curls. I need to tone it down......

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Re: Proximal ( or High) Hamstring tendonopathy

Postby vander » Mon Mar 05, 2018 11:04 pm

ValleyForge wrote:Generally repeated stressing of the affected tendon with exercise is recommended against. It is the repeated full loading and unloading of the tendon that seems to perpetuate the inflammation. Hamstring curls would not be helping in all likelihood.

This is ust incorrect. All evidence for tendinopathy shows that loading (stressing) the tendon is important and necessary.
There is rarely inflamation in tendinopathies.
Hamstring curls will be great for it just need to load it right gradually and consistency.

As your physio seems JPgibson compression can be hard (cycling has plenty of that) but isnt inherently bad it is just a load that may be harder to tolerate.

Hamstring strengthening in hip extension is a good first step. Progress to more flexion (compression) if you can handle decent hamstring loads in flexion than cycling will be fine.

Tendinopathies can be annoying and need patience. Always remember that one of the first guys to treat a tendinopathy was trying to tear the tendon and ended up fixing it by loading it lots.

Dont be afraid of pain there will be ups and downs.

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ValleyForge
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Re: Proximal ( or High) Hamstring tendonopathy

Postby ValleyForge » Tue Mar 06, 2018 3:08 pm

vander wrote:
ValleyForge wrote:Generally repeated stressing of the affected tendon with exercise is recommended against. It is the repeated full loading and unloading of the tendon that seems to perpetuate the inflammation. Hamstring curls would not be helping in all likelihood.

This is ust incorrect. All evidence for tendinopathy shows that loading (stressing) the tendon is important and necessary.

Got me interested now. Can you share this with us?
vander wrote:There is rarely inflamation in tendinopathies.

Which model are you referring to: inflammatory, mechanical, synovio-entheseal complex theory, auto-immune or genetic?

Go. 8) 8)
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jpgibson
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Re: Proximal ( or High) Hamstring tendonopathy

Postby jpgibson » Wed Mar 07, 2018 5:58 am

Evidence is scarce for this problem.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4396672/
My understanding is that there is a structural change in the tendon with repeated injury.The only evidence ( and I doubt it was an RCT) is for eccentric exercises ( I think it was in soccer players). Plenty of anecdotal 'evidence' for other treatments ( inc PRP).
In my case, I definitely get pain relief with eccentric exercises ( as I was told would occur) but I suspect I overdid the weight!
Thanks again for all the replies- I just have to be more patient!

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Re: Proximal ( or High) Hamstring tendonopathy

Postby ValleyForge » Wed Mar 07, 2018 7:16 pm

There are roughly two forms - the acute (which fits with your description) and the sub-acute or chronic type. The eccentric exercise program works well for the latter, but universally aggravates the former.

The model is where a tendon inserts into a bone, the nature of the "anchoring" is prone to poor blood supply. Also the fibroblasts which restore the collagen fibres are very slow. The pain seems to be from oedema and swelling in the tendon which worsens the blood supply. This cycle is seen in many parts of the mammalian body - in humans it is responsible for tennis elbow, golfer's thumb, the "nagging groin strain" of footballers; the list goes on.

Accept a period of limiting sudden loading of the hamstrings; then move into the recovery phase exercises. Long-acting NSAIDs from your GP will help you feel better, but not alter the end result.
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jpgibson
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Re: Proximal ( or High) Hamstring tendonopathy

Postby jpgibson » Thu Mar 08, 2018 12:29 pm

Thanks once again! Regarding definitions, I'm hoping I'm still in the 'acute' group! As you suggested, its a relapse-remitting course that varies daily. I do find that prone hamstring curls ( eccentric slower extension and fairly ( still slow) quick flexion), helps.Many days I have little to no discomfort, others i get a short sharp pain upon standing after a period of sitting- strangely mostly on Sydney trains!
I'm resigned to it taking a long time to get completely better and I'd love for it not to become semi chronic or chronic!
I dont think, based on my discomfort, I need NSAIDS at the moment.

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Re: Proximal ( or High) Hamstring tendonopathy

Postby vander » Mon Mar 12, 2018 9:53 am

jpgibson wrote:Evidence is scarce for this problem.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4396672/
My understanding is that there is a structural change in the tendon with repeated injury.The only evidence ( and I doubt it was an RCT) is for eccentric exercises ( I think it was in soccer players). Plenty of anecdotal 'evidence' for other treatments ( inc PRP).
In my case, I definitely get pain relief with eccentric exercises ( as I was told would occur) but I suspect I overdid the weight!
Thanks again for all the replies- I just have to be more patient!


No use me writing what others have done better.
https://www.tendinopathyrehab.com/blog/tendinopathy-updates/just-load-it-guest-blog-by-erik-meira
https://trustmephysiotherapy.com/9-tendinopathy-truths-must-know/
https://www.tendinopathyrehab.com/blog/tendinopathy-updates/top-tips-for-proximal-hamstring-tendinopathy-rehab


Plenty of RCTs and even systematic reviews about exercise and loading. It might not change structure but it changes pain. There is a donut hole theory which you could look up.

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ValleyForge
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Re: Proximal ( or High) Hamstring tendonopathy

Postby ValleyForge » Mon Mar 12, 2018 10:18 am

vander wrote:
jpgibson wrote:Evidence is scarce for this problem.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4396672/
My understanding is that there is a structural change in the tendon with repeated injury.The only evidence ( and I doubt it was an RCT) is for eccentric exercises ( I think it was in soccer players). Plenty of anecdotal 'evidence' for other treatments ( inc PRP).
In my case, I definitely get pain relief with eccentric exercises ( as I was told would occur) but I suspect I overdid the weight!
Thanks again for all the replies- I just have to be more patient!


No use me writing what others have done better.
https://www.tendinopathyrehab.com/blog/tendinopathy-updates/just-load-it-guest-blog-by-erik-meira
https://trustmephysiotherapy.com/9-tendinopathy-truths-must-know/
https://www.tendinopathyrehab.com/blog/tendinopathy-updates/top-tips-for-proximal-hamstring-tendinopathy-rehab


Plenty of RCTs and even systematic reviews about exercise and loading. It might not change structure but it changes pain. There is a donut hole theory which you could look up.

Great reading. The take home message (for me) is setting expectations and the progressive nature of the loading. Everyone wants to return to normal ASAP and that fuels the classic cyclic nature of symptoms.
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Re: Proximal ( or High) Hamstring tendonopathy

Postby vander » Thu Mar 15, 2018 9:35 pm

ValleyForge wrote:Great reading. The take home message (for me) is setting expectations and the progressive nature of the loading. Everyone wants to return to normal ASAP and that fuels the classic cyclic nature of symptoms.


Second one is the big point. Also the effects of detraining in peoples rest overload approach. Complete rest is contraindicated.

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Re: Proximal ( or High) Hamstring tendonopathy

Postby jpgibson » Sun Mar 18, 2018 2:32 pm

And now Ive stumbled across Cook & Purdam from 2008...mainly regarding Achilles tendinopathy. The bottom line is no one seems to have a definitive answer! I havent done any hamstring work ( eccentric) for a few days and I've had no issues. I doubt cycling will be back though. Then I read I need to give the tendon some work to do......
Then I read the above paper: need to decide if I'm in the early or late phase!
Now my head hurts!

jpgibson
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Re: Proximal ( or High) Hamstring tendonopathy

Postby jpgibson » Tue May 08, 2018 7:55 pm

Good news,bad news,badnews.
1.PHT just about gone
2.Stacked dirtbike a week ago-> # right scaphoid ( surgery)
3.Cant do anything but walk, so did 45km in 2 days ( at the age of 52), guess what? Yep can feel hamstring tendon again.
Hopefully I'll heal!

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