Sports Medicine
Sports Injury Prevention & Rehabilitation

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Hamstring Tendonitis

(Also known as Hamstring Tendinopathy, Hamstring Tendinitis, Biceps Femoris Tendinopathy)
Note - Although research suggests that 'hamstring tendinopathy' is the more appropriate term to describe overuse injuries to the hamstring tendon, we will use the term 'hamstring tendonitis' in this document as it is more widely known.

What is hamstring tendonitis?
Hamstring tendonitis is a condition characterized by tissue damage and inflammation to one or more of the hamstring tendons. This occurs at their attachment to the top of the lower leg causing pain in the back of the knee.
The hamstring muscles originate from the pelvis and insert into the top of the lower leg bones. The hamstring muscles comprise of three muscle bellies: the biceps femoris (outer hamstring) and the semimembranosus and semitendinosus (inner hamstring).The hamstring muscles attach to the outer and inner aspect of the lower leg bones via the hamstring tendons.  
The hamstring muscles are responsible for bending the knee and straightening the hip during activity and are particularly active during running, jumping and kicking. During contraction of the hamstrings, tension is placed through the hamstring tendons. When this tension is excessive due to too much repetition or high force, damage to the hamstring tendons may occur. Hamstring tendonitis is a condition whereby there is damage to one or more of the hamstring tendons with subsequent degeneration and inflammation.

Causes of hamstring tendonitis
Hamstring tendonitis most commonly occurs due to repetitive or prolonged activities placing strain on the hamstring tendon. This typically occurs due to repetitive running, jumping or kicking activities. It is also particularly common in sports requiring frequent acceleration and deceleration.
Occasionally, patients may develop this condition suddenly due to a high force going through the hamstring tendons beyond what they can withstand. This most commonly occurs during rapid acceleration whilst running or when a footballer performs a long kick.

Signs and symptoms of hamstring tendonitis
Patients with hamstring tendonitis typically experience pain that develops gradually in the inner or outer aspect of the back of the knee. In less severe cases, patients may only experience an ache or stiffness in the knee that increases with rest following activities requiring strong or repetitive contraction of the hamstring muscle. These activities typically include running, jumping or kicking. The pain associated with this condition may also warm up with activity in the initial stages of the condition.
As the condition progresses, patients may experience symptoms that increase during activity and affect performance. Patients with this condition typically experience pain on firmly touching the hamstring tendons. Occasionally, a feeling of lower limb weakness may also be present particularly when attempting to accelerate whilst running.

Diagnosis of hamstring tendonitis

A thorough subjective and objective examination from a physician is usually sufficient to diagnose hamstring tendonitis. Occasionally, further investigations such as an Ultrasound, X-ray, MRI or CT scan may be required to assist with diagnosis and assess the severity of the condition.

Prognosis of hamstring tendonitis

Most patients with this condition heal well with appropriate therapy and return to normal function in a number of weeks. Occasionally, rehabilitation can take significantly longer and may take many months in those who have had their condition for a long period of time. Early therapy treatment is vital to hasten recovery in all patients with this condition.

Treatment for hamstring tendonitis
The success rate of treatment for hamstring tendonitis is largely dictated by patient compliance. One of the key components of treatment is that the patient rests from ANY activity that increases their pain until they are symptom free. This allows the body to begin the healing process in the absence of further tissue damage to the hamstring tendon. Once the patient can perform these activities pain free, a gradual return to these activities is indicated provided there is no increase in symptoms.
Ignoring symptoms or adopting a 'no pain, no gain' attitude is likely to lead to the condition becoming chronic. Immediate, appropriate treatment in all patients is essential to ensure a speedy recovery. Once the condition is chronic, healing slows significantly resulting in markedly increased recovery times and an increased likelihood of future recurrence.
Patients with hamstring tendonitis should follow RICE in the initial phase of injury. RICE is beneficial in the first 72 hours following injury or when inflammatory signs are present (i.e. morning pain or pain with rest). RICE involves resting from aggravating activities, regular icing, the use of a compression bandage and keeping the affected leg elevated. Anti-inflammatory medication may also significantly hasten the healing process by reducing the pain and swelling associated with inflammation.
Patients with this condition should undergo a graduated flexibility and strengthening program of the hamstrings to ensure an optimal outcome. The treating therapist can advise which exercises are most appropriate for the patient and when they should be commenced.
In the final stages of rehabilitation, a graduated return to running program is required to recondition the hamstring muscle for running in a safe and effective manner. This should include the implementation of progressive acceleration and deceleration running drills and should be guided by the treating therapist.

Contributing factors to the development of hamstring tendonitis
There are several factors which can predispose patients to developing this condition. These need to be assessed and corrected with direction from a therapist. Some of these factors include:
  • joint stiffness (particularly the hip, knee and lower back)
  • muscle tightness (particularly the hamstrings and quadriceps)
  • inappropriate or excessive training
  • inadequate warm up
  • muscle weakness (especially the hamstrings and gluteals)
  • poor pelvic or core stability
  • inadequate rehabilitation following a previous hamstring injury

Therapy for hamstring tendonitis
Therapy treatment is vital to hasten the healing process, ensure an optimal outcome and reduce the likelihood of injury recurrence. Treatment may comprise:
  • soft tissue massage
  • electrotherapy (e.g. ultrasound)
  • stretches
  • joint mobilization
  • ice or heat treatment
  • exercises to improve strength, flexibility and core stability
  • education
  • anti-inflammatory advice
  • activity modification advice
  • a gradual return to activity program

Other intervention for hamstring tendonitis
Despite appropriate therapy management, some patients with hamstring tendonitis do not improve adequately. When this occurs the treating therapist or doctor will advise on the best course of management. This may include further investigations such as X-rays, ultrasound, MRI or CT scan, pharmaceutical intervention, corticosteroid injection or referral to appropriate medical authorities who will advise on any interventions that may be appropriate to improve the condition.