An elite male player presented with a three-month history of increasing buttock discomfort. This was initially well localised but then became more generalised with referral into the distal hamstring. The pain was made worse by striding out (sprinting) and with prolonged sitting.
On examination there was a reduced straight leg raise, pain with bridging exercise and localised tenderness about the proximal hamstring and ischial tuberosity. There was a normal hip and lumbar spine examination. A provisional diagnosis of proximal hamstring tendinopathy was made.
An x-ray image of the hip and pelvis was normal. MRI has demonstrated changes consistent with tendinopathy involving the left proximal hamstring. There is a small amount of intermediate T1 and increased T2 signal on the left. The tendon is slightly thickened compared with the right. There is also a small amount of reactive change in the ischial tuberosity. No tendon tear is present. The proximal hamstring muscles were otherwise normal in signal and are symmetrical in bulk with the right.
This player was treated with a progressive strengthening programme. This started with isometric loading but progressed to involve eccentric strengthening (predominantly involving a single leg bridge exercise). As the symptoms were initially quite significant he required a short period (less than three weeks) away from football training. After this he was able to continue playing matches with a reduced training load. It took almost six months for the symptoms to completely resolve.
Proximal hamstring tendinopathy is a relatively uncommon cause of buttock pain. Symptoms are generally worse with prolonged sitting and when striding out (sprinting). The pain can refer into the distal hamstring and can occasionally create weakness and altered sensation due to its proximity to the sciatic nerve. Tenderness about the proximal hamstring, pain with stretching and pain with resisted hamstring contractions are common clinical findings.
As with tendinopathy in other regions, proximal hamstring tendinopathy is generally best treated with a progressive strengthening programme. Other modalities (including shock wave therapy, PRP injections or steroid injections) can have a role in some situations. Very rarely surgical debridement of the tendon is needed.
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