Diagnosing Chronic High (Proximal) Hamstring Tendinopathy

The diagnostic process will begin with a patient interview and physical exam and possibly include medical imaging.

Patient Interview

A doctor will ask the patient about pain history, the pattern of pain, and how symptoms affect lifestyle and training. The patient should be sure to report previous injures to the affected area, such as a history of high (proximal) hamstring tear, even if it occurred years earlier.

Physical Exam

The doctor will use the physical exam to approximate the location and severity of the injury. The doctor will try to replicate the patient’s symptoms by palpitating the painful area, passively moving the patient’s limbs, and asking the patient to perform certain physical activities.

Patients with chronic high (proximal) hamstring tendinopathy will often have pain with sitting and tenderness to palpation at the sit bone (ischial tuberosity). Similar to acute hamstring strains, chronic tendinopathy may demonstrate side-to-side differences in range of motion, with pain at the sit bone (ischial tuberosity) at the end range of hip flexion.¹Lempainen L, Sarimo J, Mattila K, Vaittinen S, Orava S. Proximal hamstring tendinopathy: results of surgical management and histopathologic findings. Am J Sports Med 2009;37:727-34.^,2Zissen M, Wallace G, Stevens K, Fredericson M, Beaulieu C. High hamstring tendinopathy: MRI and ultrasound imaging and therapeutic efficacy of percutaneous corticosteroid injection. AJR Am J Roentgenol 2010;195:993-8.^,3Cacchio A, Borra F, Severini G, et al. Reliability and validity of three pain provocation tests used for the diagnosis of chronic proximal hamstring tendinopathy. Br J Sports Med 2012;46:883-7. Several provocative tests with high sensitivity have been described for chronic proximal hamstring tendinopathy, such as the Puranen-Orava test, the bent-knee stretch test, and the modified bent-knee stretch test..FOOT|3]

Occasionally, the hamstring tendon can develop scar tissue that entraps the sciatic nerve, resulting in radiating pain down the affected leg.⁴Puranen J, Orava S. The hamstring syndrome--a new gluteal sciatica. Ann Chir Gynaecol 1991;80:212-4. The medical professional will be careful to rule out other causes of radiating leg pain, such as a pinched nerve in the lower back (such as from an L5-S1 herniated disc with an S1 radiculopathy), a sacroiliac dysfunction, or other nerve entrapment. It is, therefore, important to have a complete musculoskeletal and neurological examination by a qualified medical professional.

Advanced imaging

There are several available imaging techniques for chronic hamstring injuries. X-rays of the hip/pelvis are often negative in athletes with chronic high (proximal) hamstring injuries unless there is bony ingrowth within the hamstring tendon at the sit bone (Ischial tuberosity) called enthesopathy.⁵Ali K, Leland J. Hamstring strains and tears in the athlete. Clin Sports Med 2012;31:263-72.^-.⁷Clanton T, Coupe K. Hamstring strains in athletes: diagnosis and treatment. J Am Acad Orthop Surg 1998;6:237-48. Advanced imaging with MRI or dynamic ultrasound (sonography), may be required to determine the severity of injury.⁸Connell D, Schneider-Kolsky M, Hoving J, et al. Longitudinal study comparing sonographic and MRI assessments of acute and healing hamstring injuries. AJR Am J Roentgenol 2004;183:975-84.^-.¹²Lin J, Jacobson J, Fessell D, Weadock W, Hayes C. An illustrated tutorial of musculoskeletal sonography: part 4, musculoskeletal masses, sonographically guided interventions, and miscellaneous topics. AJR Am J Roentgenol 2000;175:1711-9. When available, musculoskeletal ultrasound provides several advantages over x-ray, computed tomography (CT) and MRI, including decreased cost, portability, lack of ionizing radiation, and exquisite soft tissue imaging.¹³Smith J, Finnoff J. Diagnostic and interventional musculoskeletal ultrasound: part 1. Fundamentals. PM R 2009;1:64-75.^{, 14}Smith J, Finnoff J. Diagnostic and interventional musculoskeletal ultrasound: part 2. Clinical applications. PM R 2009;1:162-77. Furthermore, ultrasound can provide the availability to test the tissues dynamically to rule in or out other diagnoses, and it has been found to be extremely accurate and precise at determining the location and extent of a hamstring injury.⁵Ali K, Leland J. Hamstring strains and tears in the athlete. Clin Sports Med 2012;31:263-72.^,10Mariani C, Caldera F, Kim W. Ultrasound versus magnetic resonance imaging in the diagnosis of an acute hamstring tear. PM R 2012;4:154-5. Ultrasound may be limited by a patient’s physique or body type and therefore other imaging modalities may be more appropriate. In cases where there is significant loss of function, it is important to determine the extent of injury to help guide treatment and possibly predict return to activity.¹¹Rettig A, Meyers S, Kersey P, Ballard G, Oneacre K, Hunker P. Categorization of Hamstring Strain Injuries by MRI and PLaying Time Lost in Professional Football Players. NATA 2008:29-32.^,15Schneider-Kolsky M, Hoving J, Warren P, Connell D. A comparison between clinical assessment and magnetic resonance imaging of acute hamstring injuries. Am J Sports Med 2006;34:1008-15.

In severe cases, a doctor may wish to order magnetic resonance imaging (MRI). An MRI can provide an accurate picture of the severity of the injury as well as surrounding structures, such as the sciatic nerve and sacroiliac joint, depending on the imaging ordered. It may be important in cases where the diagnosis is uncertain. MRI can also be useful in eliminating other potential diagnoses, such as sit bone (ischial) bursitis.