Fluoroscopically Guided Peritendinous Corticosteroid Injection for Proximal Hamstring Tendinopathy: A Retrospective Review

A pilot randomised trial comparing individualised physiotherapy versus shockwave therapy for proximal hamstring tendinopathy: a protocol

PURPOSE

Proximal hamstring tendinopathy (PHT) presents as localised lower buttock pain with tasks such as squatting and sitting. It is a condition that occurs at all ages and levels of sporting participation and can cause disability with sport, work, and activities of daily living. This paper details a pilot trial protocol for investigating the effectiveness of individualised physiotherapy compared to extracorporeal shockwave therapy (ESWT) on pain and strength in people with PHT.

METHODS

The study is an assessor-blinded, pilot randomised controlled trial (RCT). One hundred participants with PHT will be recruited from the local community and sporting clubs. Participants will be randomised to receive six sessions of either individualised physiotherapy or ESWT, with both groups also receiving standardised education and advice. Primary outcomes will be global rating of change on a 7-point Likert scale, and the Victorian Institute of Sport-Hamstring (VISA-H) scale, measured at 0, 4, 12, 26 and 52 weeks. Secondary outcomes will include sitting tolerance, the modified Physical Activity Level Scale, eccentric hamstring strength, modified Tampa scale for kinesiophobia, the Örebro Musculoskeletal Pain Screening Questionnaire Short Form (ÖMPSQ-SF), Numerical Pain Rating Scale (NPRS) for average and worst pain, participant adherence, the Pain Catastrophizing scale, satisfaction scores, and quality of life. Data will be analysed on an intention to treat basis, with between-group effects estimated using linear mixed models for continuous data and Mann Whitney U tests for ordinal data.

CONCLUSIONS

This pilot RCT will compare individualised physiotherapy versus ESWT for PHT. The trial will determine feasibility and estimated treatment effects to inform a definitive trial in the future.

TRIAL REGISTRATION

The trial has been prospectively registered with the Australia & New Zealand Clinical Trials Registry (ACTRN12621000846820), registered 1 July 2021, https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=373085.

Proximal Hamstring Tendinopathy: A Systematic Review of Interventions

BACKGROUND

Proximal hamstring tendinopathy affects athletic and non-athletic populations and is associated with longstanding buttock pain. The condition is common in track and field, long distance running and field-based sports. Management options need to be evaluated to direct appropriate clinical management.

PURPOSE/HYPOTHESIS

To evaluate surgical and non-surgical interventions used in managing proximal hamstring tendinopathy.

STUDY DESIGN

Systematic review.

METHODS

Electronic databases were searched to January 2019. Studies (all designs) investigating interventions for people with proximal hamstring tendinopathy were eligible. Outcomes included symptoms, physical function, quality of life and adverse events. Studies were screened for risk of bias. Reporting quality was assessed using the Cochrane Risk of Bias Tool (Randomized Controlled Trials [RCT]) and the Joanna Briggs Institute Checklist (Case Series). Effect sizes (Standard mean difference or Standard paired difference) of 0.2, 0.5 and 0.8 were considered as small, medium and large respectively. Overall quality of evidence was rated according to GRADE guidelines.

RESULTS

Twelve studies (2 RCTs and 10 case series) were included (n=424; males 229). RCTs examined the following interventions: platelet-rich plasma injection (n=1), autologous whole-blood injection (n=1), shockwave therapy (n=1) and multi-modal intervention (n=1). Case series included evaluation of the following interventions: platelet-rich plasma injection (n=3), surgery (n=4), corticosteroid injection (n=2), multi-modal intervention + platelet-rich plasma injection (n=1). Very low-level evidence found shockwave therapy was more effective than a multi-modal intervention, by a large effect on improving symptoms (-3.22 SMD; 95% CI -4.28, -2.16) and physical function (-2.42 SMD; 95% CI-3.33, -1.50) in the long-term. There was very low-level evidence of no difference between autologous whole-blood injection and platelet-rich plasma injection on physical function (0.17 SMD; 95% CI -0.86, 1.21) to (0.24 SMD; 95% CI -0.76, 1.24) and quality of life (-0.04 SMD; 95%CI -1.05, 0.97) in the medium-term. There was very low-quality evidence that surgery resulted in a large reduction in symptoms (-1.89 SPD; 95% CI -2.36, -1.41) to (-6.02 SPD; 95% CI -8.10, -3.94) and physical function (-4.08 SPD; 95%CI -5.53, -2.63) in the long-term.

CONCLUSIONS

There is insufficient evidence to recommend any one intervention over another. A pragmatic approach would be to initially trial approaches proven successful in other tendinopathies.

LEVEL OF EVIDENCE

Level 2a.

Proximal Hamstring Injuries

Proximal hamstring injuries can present as chronic tendinosis, acute strain, partial tendinous avulsions, or complete 3-tendon rupture. Nonoperative management for chronic insertional tendinosis and low-grade tears includes activity modification, anti-inflammatories, and physical therapy. Platelet-rich plasma injections, corticosteroid injections, dry needling, and shock wave therapy are newer therapies that also may provide benefit. Surgical indications include complete, proximal avulsions; partial avulsions with least 2 tendons injured with more than 2 cm of retraction in young, active patients; and partial avulsion injuries or chronic tendinosis that have failed nonoperative management. Surgical management entails open primary repair, endoscopic primary repair, or augmentation/reconstruction.

Proximal hamstring tendinopathy; expert physiotherapists' perspectives on diagnosis, management and prevention

OBJECTIVES

To explore and summarise expert physiotherapists' perceptions on their assessment, management and prevention of proximal hamstring tendinopathy (PHT).

METHODS

We conducted semi-structured interviews with expert physiotherapists until data saturation was met (n = 13). Interviews were transcribed verbatim and data were analysed systematically and organised into categories and sub-categories according to study aims.

RESULTS

Experts report using a clinical reasoning-based approach, incorporating information from the patient interview and results of clinical load-based provocation tests, in the physical examination to diagnose PHT. Experts manage the condition through education and progressive loading targeting the hamstring unit and kinetic chain, avoiding provocative activities in positions of compression in early-mid stage rehab and a gradated and controlled return to sport. Passive therapies including injection therapies and surgery were believed to have limited utility. Prevention of recurrence primarily involved continuation of hamstring and kinetic chain strengthening programs and management of physical workload.

CONCLUSION

Experts rely on a combination of information from the patient interview and a battery of pain provocation tests to diagnose PHT. Education and graded exercise of the hamstring group and synergists, minimising early exposure to hip flexion, were the foundation of management of the condition.

Platelet-rich plasma for treatment of chronic proximal hamstring tendinopathy

Aim: To determine whether platelet-rich plasma (PRP) can successfully treat symptoms associated with proximal hamstring tendinopathy. Materials & methods: Charts were retrospectively reviewed of patients with a diagnosis of chronic proximal hamstring tendinopathy who underwent an ultrasound-guided leukocyte-rich PRP injection to assess reported outcomes at baseline and final follow-up post-intervention. Results: In 22 patients with a mean age of 48.7 years and mean symptom duration of 26.5 months, mean Numeric Pain Rating Scale and Victorian Institute of Sport Assessment Scale for Proximal Hamstring Tendinopathy subscores demonstrated statistically significant improvements (p < 0.05) at a mean of 7.91 months follow-up. Sixty-eight percent of patients demonstrated ≥50% reduction of pain. Conclusion: Pain and functional outcomes improved following injection of PRP.

Nonbiologic Injections in Sports Medicine

Nonbiologic medications (local anesthetics, corticosteroids, and nonsteroidal anti-inflammatory drugs) are commonly administered to athletes for analgesia after injury. However, the risks of nonbiologic injections often are overlooked simply because of their long-term market availability. A thorough understanding of the mechanism of action, the reported benefits, and the potential risks of nonbiologic medications is crucial prior to their use, especially in the treatment of young athletes. Sports medicine physicians and surgeons must be aware of the systemic and local effects of these medications to ensure an appropriate drug choice that minimizes side effects and avoids recently reported toxicity to myocytes, tenocytes, and chondrocytes.

Orthobiologics for the Hip Region: A Narrative Review

Management of hip region disorders is challenging. Orthobiologic treatments including platelet rich plasma (PRP), mesenchymal stem cells, and amniotic injectables have gained popularity as promising treatments despite a lack of robust evidence for their effectiveness. We review rationale and current evidence for orthobiologics for three common hip region conditions: hip osteoarthritis, gluteal tendinopathy, and proximal hamstring tendinopathy. Overall, the current state of evidence is extremely limited for orthobiologic treatments and is predominantly relevant to PRP injections. There is currently a lack of data to support the use of mesenchymal stem cells or amniotic injectables in these conditions of the hip.

Proximal Hamstring Injuries: Management of Tendinopathy and Avulsion Injuries

PURPOSE OF REVIEW

To outline the typical presentation, physical examination, diagnostic imaging, and therapeutic treatment options for proximal hamstring injuries to improve awareness, expedient diagnosis, and definitive management.

RECENT FINDINGS

Proximal hamstring tendinopathy and partial-thickness tears can often successfully be managed with a combination of non-operative modalities, including physiotherapy focused on eccentric strengthening, extracorporeal shock wave therapy, or peri-tendinous injections. Surgery is reserved for refractory cases, but can yield good outcomes. Contrastingly, non-operative treatment often leads to unsatisfactory outcomes in complete ruptures, with residual weakness and reduced function with poor return-to-sport rates. Instead, surgical repair can provide satisfactory outcomes, with good-to-excellent functional outcomes and strength, with acute treatment preferred over delayed, chronic repair. Hamstring tendinopathy and partial-thickness tears can be successfully treated non-operatively with good functional outcomes, with surgical repair reserved for refractory cases. Complete tears are best managed with surgical repair, allowing improved strength and functional outcomes.

Differing MRI appearances of symptomatic proximal hamstring tendinopathy with ageing: a comparison of appearances in patients below and above 45 years

AIM

To compare magnetic resonance imaging (MRI) appearances of symptomatic proximal hamstring tendinopathy (PHT) in younger (<45 years) and older (>45 years) patients.

MATERIALS AND METHODS

MRI of patients with symptomatic PHT were reviewed and compared to asymptomatic age- and sex-matched controls. Appearances recorded were as: type 0, normal tendon; type I, intra-substance signal abnormality; type II, ischial bone and soft-tissue oedema with/without type I findings; type III, curvilinear fluid signal tearing with/without type II findings; type IV, bony avulsion. Disease pattern was compared between age groups using Fisher's exact test.

RESULTS

Thirty-one symptomatic patients (18 male, 13 female; mean age 42 years) were identified. Imaging findings of 16 patients >45 years, 15 patients <45 were as follows: type 0 n=8, type I n=7, type II n=6, type III n=10, type IV n=0. Those >45 years tended to have type III tendinopathy, no examples of type III disease were found in patients <45 years (p<0.001). No significant difference in disease pattern was seen between males and females (p=0.39). Seven of 31 controls >45 years had type III findings and four controls <45 years had type I findings.

CONCLUSION

MRI appearances of symptomatic PHT differ with age. Differences may reflect mechanism, whereby overuse-related micro-tearing of healthy tendons occurs in young patients versus degenerative tendinopathy in older patients. Abnormal tendon appearances in patients >45 years may or may not be symptomatic. In contrast, abnormalities identified in younger patients are generally symptomatic. These described differences are important in the primary diagnosis and may impact upon patient response to therapy.

Efficacy of a platelet-rich plasma injection for the treatment of proximal hamstring tendinopathy: A pilot study

OBJECTIVES

To determine the efficacy of an ultrasound-guided platelet-rich plasma (PRP) injection in the treatment of patients with proximal hamstring tendinopathy (PHT).

DESIGN

Pilot prospective cohort study METHODS: Administration of a single PRP injection under ultrasound guidance to 29 patients with PHT confirmed on magnetic resonance imaging (MRI). Pain, function and sporting activity were measured via the Victorian Institute of Sport Assessment-Proximal Hamstring Tendons (VISA-H) questionnaire, administered before injection and at 8-weeks follow-up.

RESULTS

The study sample consisted of 22 females and 7 males with a mean age of 45.2 years (95% CI 40.8-49.5). When comparing pre-injection VISA-H scores (mean: 43.90; 95% CI 37.77-50.03) with 8-week post-injection VISA-H scores (mean: 51.14; 95% CI 43.39-58.88) in the total sample of patients, no statistically significant difference was found (p=0.14). When performing separate analyses for patients with mild (n=9), moderate (n=16) or marked (n=4) PHT, no statistically significant difference was found in pre-and post-injection VISA-H scores for any of the groups (p=0.86, p=0.13, p=0.28 respectively). 69% of patients reported no change in their ability to undertake sport or other physical activity at 8-weeks follow-up.

CONCLUSIONS

Patients with PHT receiving a PRP injection did not improve on clinical outcomes at 8-weeks follow-up.

Tendinopathy: injury, repair, and current exploration

Both acute and chronic tendinopathy result in high morbidity, requiring management that is often lengthy and expensive. However, limited and conflicting scientific evidence surrounding current management options has presented a challenge when trying to identify the best treatment for tendinopathy. As a result of shortcomings of current treatments, response to available therapies is often poor, resulting in frustration in both patients and physicians. Due to a lack of understanding of basic tendon-cell biology, further scientific investigation is needed in the field for the development of biological solutions. Optimization of new delivery systems and therapies that spatially and temporally mimic normal tendon physiology hold promise for clinical application. This review focuses on the clinical importance of tendinopathy, the structure of healthy tendons, tendon injury, and healing, and a discussion of current approaches for treatment that highlight the need for the development of new nonsurgical interventions.

Rehabilitation and Prevention of Proximal Hamstring Tendinopathy

Proximal hamstring tendinopathy (PHT) comprises a small but significant portion of hamstring injuries in athletes, especially runners. PHT is a chronic condition that is clinically diagnosed but can be supported with imaging. The main presenting complaint is pain in the lower gluteal or ischial region that may or may not radiate along the hamstrings in the posterior thigh. There is little scientific evidence on which to base the rehabilitation management of PHT. Treatment is almost always conservative, with a focus on activity modification, addressing contributing biomechanical deficiencies, effective tendon loading including eccentric training, and ultrasound-guided interventional procedures which may facilitate rehabilitation. Surgery is limited to recalcitrant cases or those involving concomitant high-grade musculotendinous pathology. The keys to PHT management include early and accurate diagnosis, optimal rehabilitation to allow for a safe return to preinjury activity level, and preventative strategies to reduce risk of reinjury.

Hamstring Injuries in the Athlete: Diagnosis, Treatment, and Return to Play

Hamstring injuries are very common in athletes. Acute hamstring strains can occur with high-speed running or with excessive hamstring lengthening. Athletes with proximal hamstring tendinopathy often do not report a specific inciting event; instead, they develop the pathology from chronic overuse. A thorough history and physical examination is important to determine the appropriate diagnosis and rule out other causes of posterior thigh pain. Conservative management of hamstring strains involves a rehabilitation protocol that gradually increases intensity and range of motion, and progresses to sport-specific and neuromuscular control exercises. Eccentric strengthening exercises are used for management of proximal hamstring tendinopathy. Studies investigating corticosteroid and platelet-rich plasma injections have mixed results. Magnetic resonance imaging and ultrasound are effective for identification of hamstring strains and tendinopathy but have not demonstrated correlation with return to play. The article focuses on diagnosis, treatment, and return-to-play considerations for acute hamstring strains and proximal hamstring tendinopathy in the athlete.

Expert opinion: diagnosis and treatment of proximal hamstring tendinopathy

BACKGROUND

proximal hamstring tendinopathy (PHT) is a disabilitating disease often causing underperformance in the athletically demanding patients. The main symptom of PHT is lower gluteal pain especially during running or while prolonged sitting. Mainly affecting athletically active individuals, PHT is a considerable challenge for treating health care professionals.

PURPOSE

this paper aims to concisely present the literature on PHT to guide health care professionals treating these patients and doing research on the subject.

METHODS

we reviewed the literature on PHT through literature search of scientific journal databases.

CONCLUSIONS

as a tendinopathic pathology, it is a rather recently discovered exertion injury. As with other chronic tendon overuse injuries, current treatment strategies are unspecific with uncertain outcomes due to the unknown etiology of the tendon degeneration. Diagnostic features as well as both operative and non-operative treatments are evaluated from a clinical perspective, providing up to date information for clinicians and sports medicine therapists dealing with hamstring problems.

LEVEL OF EVIDENCE

V.