Physical Therapy in Sport 48 (2021) 67e75

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Physical Therapy in Sport

journal homepage: www.elsevier.com/ptsp

Original Research

Proximal hamstring tendinopathy; expert physiotherapists’

perspectives on diagnosis, management and prevention
Anthony M. Nasser a, d, *, Tania Pizzari a, Alison Grimaldi b, Bill Vicenzino b, Ebonie Rio a,
Adam Ivan Semciw a, c
a
La Trobe Sports and Exercise Medicine Research Centre, La Trobe University, Bundoora, Victoria, Australia
b
School of Health and Rehabilitation Sciences, University of Queensland, Australia
c
Northern Centre for Health Education and Research, Northern Health, Victoria, Australia
d
University of Technology Sydney, Graduate School of Health, Australia

a r t i c l e i n f o a b s t r a c t

Article history: Objectives: To explore and summarise expert physiotherapists’ perceptions on their assessment, man-
Received 13 October 2020 agement and prevention of proximal hamstring tendinopathy (PHT).
Received in revised form Methods: We conducted semi-structured interviews with expert physiotherapists until data saturation
5 December 2020
was met (n ¼ 13). Interviews were transcribed verbatim and data were analysed systematically and
Accepted 8 December 2020
organised into categories and sub-categories according to study aims.
Results: Experts report using a clinical reasoning-based approach, incorporating information from the
Keywords:
patient interview and results of clinical load-based provocation tests, in the physical examination to
Buttock
Hamstring
diagnose PHT. Experts manage the condition through education and progressive loading targeting the
Tendinopathy 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 contin-
uation 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.
Crown Copyright © 2020 Published by Elsevier Ltd. All rights reserved.

1. Introduction interventions, including exercise, corticosteroid injection, platelet-

rich plasma injection, shockwave therapy and surgery (Nasser et al.,
Proximal hamstring tendinopathy (PHT) affects athletic and 2020). This review reported a lack of unbiased estimates of strong
non-athletic populations and is associated with longstanding treatment effects to guide treatment selection (Nasser et al., 2020).
ischial pain (Goom et al., 2016; Lempainen et al., 2009a, 2015). The With no high quality evidence, clinicians are left with a lack of
research on prevalence is limited, however PHT has been consis- direction to guide management (Goom et al., 2016).
tently identified in sports involving running such as Australian In the absence of strong empirical evidence, qualitative research
Rules football, tennis and track and field, as well as sedentary provides insight to the expert’s clinical reasoning process and as-
populations (Benazzo et al., 2013; Cacchio et al., 2011; Goom et al., sists in understanding the decisions and complexities faced in
2016). Pain is frequently aggravated by activities such as hill current practice (Bolling et al., 2019; Draper, 2009). This expert
running and sitting (Cacchio et al., 2011; Goom et al., 2016; opinion can be used to assist in development of management
Lempainen et al., 2015). protocols, which can be used clinically and tested in randomised
A recent systematic review identified multiple potential clinical trials. Our aim was to explore and then summarise expert

* Corresponding author. La Trobe Sports and Exercise Medicine Research Centre, La Trobe University, Bundoora, Victoria, Australia.
E-mail address: [email protected] (A.M. Nasser).

https://doi.org/10.1016/j.ptsp.2020.12.008
1466-853X/Crown Copyright © 2020 Published by Elsevier Ltd. All rights reserved.
A.M. Nasser, T. Pizzari, A. Grimaldi et al. Physical Therapy in Sport 48 (2021) 67e75

physiotherapists’ perceptions on their assessment, management et al., 2009a), New Zealand (Lempainen et al., 2009a), Qatar
and prevention of PHT. (Lempainen et al., 2009a) and Scotland (Lempainen et al., 2009a)
with experience across multiple sports at an elite level. Mean
2. Methods interview time was 44 min (range 31e78). All experts had experi-
ence working with the general population and professional level
2.1. Study design sport. Sports included netball, Australian Football, soccer, ballet,
race walking, touch football, weight lifting, rugby and running.
We conducted semi-structured interviews consisting of ques-
tions devised a priori to gauge the opinion of expert physiothera- 3.2. Diagnosis
pists on clinical aspects of PHT (Appendix 1). Our data were
analysed continuously during collection to establish when satura- All respondents used a combination of findings from the patient
tion was reached e indicating that no new information or themes interview and clinical examination to come to the diagnosis of PHT
were observed. Ethical approval was obtained (ID 2018001158). (Fig. 1).

2.2. Participants
3.3. Patient interview findings
We selected participants using purposeful sampling, with au-
All experts reported that the onset of PHT was insidious and
thors ensuring the sample of experts were from a range of
associated with an increase in mechanical load through the prox-
geographical locations and had experience across different sporting
imal hamstring tendon (Table 1). All experts reported that patients
populations. Participant inclusion criteria was decided a priori.
described pain at the proximal hamstring insertion at the ischial
Expert physiotherapists were selected by the investigators as in-
tuberosity and most experts agreed that the pain did not shift or
dividuals who had published in the topic area and/or had extensive
spread. “It has to be around the proximal hamstring tendon” (Expert
clinical experience in treating patients with PHT. Expert physio-
5). A shift or spread in pain was often expressed to indicate a dif-
therapists (participants) were also required to be: i) registered
ferential diagnosis or co-morbidity. Four experts (31%) reported
physiotherapists with experience treating people who have PHT ii)
that the symptoms primarily occurred at the hamstring insertion,
hold a Master’s degree or Doctor of Philosophy and iii) have a
although pain did at times spread down the hamstring, but not past
minimum of 10 years’ experience.
the knee.
Typically, patients described a spike in energy-storage-release
2.3. Data collection
(fast tensile) loads, particularly in combination with hip flexion
(e.g. increased volume of running up hills). Provocative activities
Experts were approached via email by a single investigator (AN).
included activities such as lunging, running up hills and hamstring
Interviews were performed in English online using Zoom © soft-
stretching, or activities that placed compressive loads through the
ware or via telephone. A male interviewer (AN) performed, recor-
proximal hamstring tendon-unit, such as sitting.
ded and transcribed all interviews. The interviewer was a PhD
candidate, and an Australian registered physiotherapist of 10 years,
with a Master’s degree in sports physiotherapy. Expert physio- 3.4. Clinical tests
therapists were emailed the list of interview questions prior to the
interview. All interviews were recorded and transcribed verbatim 3.4.1. Loading tests
and returned to participants for comment and/or correction. Two of All experts performed a battery of clinical tests to form a diag-
the experts interviewed were authors on the paper, but were not nosis (Table 1). Most respondents used progressive load-based
involved in coding or analysing results, and had no conflicts of in-
terest. Interviews were conducted until the same constructs
repeated themselves and no additional new themes emerged. No
repeat interviews were performed.

2.4. Data analysis

Qualitative content analysis was used to analyse data. Audio files

were transcribed and read multiple times to gain a sense of
recurrent themes. Two independent researchers (AN & TP) ana-
lysed data systematically for meaning and then condensed, coded
and organised these into categories and sub-categories according to
the study aims. The computer software NVivo 12 (QSR International
Pty Ltd version 12.5.0) was used to assist with organisation of data.
Categories and sub-categories were then compared for similarities
and differences.

3. Results

3.1. Expert demographics

Fourteen experts were contacted and agreed to participate. One

expert subsequently declined due to illness. Average clinical
experience of the 13 experts (8 males) was 25-years (range 11e42). Fig. 1. The flow chart illustrates the diagnostic process used by experts in diagnosis
Experts worked in Australia (Scott et al., 2019), Ireland (Lempainen and identification of contributing factors.

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A.M. Nasser, T. Pizzari, A. Grimaldi et al. Physical Therapy in Sport 48 (2021) 67e75

response tests, where loads placed on the hamstring tendon were 3.4.2. Palpation
progressed from low to high through a sequence of successive tests. Some experts believed it was important to be able to reproduce
Tests were considered positive if localised pain at the ischial tu- the patient’s symptoms on palpation, whereas other respondents
berosity was reproduced and increased with tasks that placed thought palpation was either of no use or had limited diagnostic
greater loads on the hamstring. Experts commonly used loads value (Table 1). Several experts believed that failing to palpate the
involving forward trunk inclination in standing with extended entire footprint of the hamstring insertion, in particular the
knee(s) (e.g. single leg Romanian deadlift, arabesque, trunk on leg attachment of the semimembranosus on the lateral aspect of the
flexion). Other, isolated pain-provocation tests commonly used ischium, was why clinicians have difficulty reproducing the pa-
were the single leg bridge test in 90 degrees of hip flexion, iso- tient’s symptoms on palpation.
metric knee flexion at 90 degrees of hip flexion and knee extension,
bent knee stretch test and modified bent knee stretch test.

Table 1
Key points and related quotes on diagnoses of proximal hamstring tendinopathy.

Patient interview

Key points: Related quotes in response to questions regarding the patient interview:

 Insidious onset  “The mechanism is the big thing. Particularly in rugby, you know the ones you want to scan straight off, whereas
the history for these types of things are going to be the load related factor. Most of the time being a lingering thing
that has got a bit worse. Insidious like.” Expert 6
 Spike in training load  “History leading up to it. So, in the younger running group, or the active group, there is often some sort of history
of change in load. So, it might have been coming up to an event and they’ve increased mileage or very commonly
in our runners it is doing hill running, and often back to back hill running, and often without adequate rest
between.” Expert 12
 No shift in direct area of pain at ischial tuberosity with  But the thing I’m looking for there is a really well localised area. That is the area that they get any time they
loading stretch it or do their provocative exercise. And critically, the area doesn’t change.” Expert 13
 Aggravated by direct compression (e.g. sitting)  " … I’m looking for aggravating factors that I would associate with being high tendon load. Often compression is
 Aggravated by activities that involve hip/trunk flexion an aggravating factor and particularly those combined things for tendons.” Expert 2
and contraction of the hamstring unit  “These are worse I think in more hip flexion and worse with direct pressure. So, that is why if you are sitting with
your hip in flexion you’re getting that compressive load on the underside of the tendon.” Expert 7

Clinical examination
Key points: Related quotes in response to questions regarding the clinical examination:

 A battery of load-based tests should be used to diagnose  “… we’d start with slower movements and increase speed and then in terms of the proximal hamstring, we
PHT would increase speed with compression. So, going into a body on leg movement, an arabesque and we’re
 Screen for contributing factors (e.g. impairments) looking for localised pain with those low load tests where as you increase the speed and therefore the load
- Requires individual assessment for the tendon the pain remains localised”. Expert 2
- Relationship to previous injuries  “So, looking for localised pain that stays localised to load, and a load dependent increase in pain. So,
reproducing that (the athlete’s pain) with a double leg body on leg flexion, then a single leg body on leg
flexion, double leg fast body on leg flexion, then single leg fast body on leg flexion” Expert 11
 Findings on palpation and imaging should be interpreted  “Palpation is a funny one. Sometimes I think patients have hamstring tendinopathy, but are not necessarily
with caution sore on palpation. But I definitely use it in the bag of things you use to come to clinical diagnosis.” Expert 3
 “Probably one of the other big things is palpation, so palpation at the tendon insertion, and that reproduces
their pain and localises the area of their pain.” Expert 4
 Hamstring, triceps surae and gluteus maximus strength  “I think observation is really important. Trying to pick up if there is any hamstring wasting or not. If there is
often reduced no hamstring wasting um, I tend to prick up my ears a bit more. Because people who have had long standing
 Hamstring muscle atrophy ones, apart from the middle-aged women, people will tend to have inhibition of hamstring if they’ve been
long standing.” Expert 13

Imaging
Key points: Related quotes in response to questions regarding the utility of imaging:

 Imaging is not required to diagnose PHT, but is used to  “I don’t think you have to have imaging for the diagnosis. I’m quite comfortable making a clinical diagnosis
aid differential diagnosis because I’ve seen a lot of these.” Expert 1
 “I don’t. I don’t, so my thinking would be if they are not progressing in 12 weeks, then I would probably send them
for imaging at that point.” Expert 5
 Signs of PHT on imaging are common in the  “On occasions yes, I would use imaging. With the difficult ones probably, a combination of MR and ultrasound …
asymptomatic population It does give you some indication if there are some perineural issues. And it does, you know, define the pathology
site. But the thing is that, like all tendinopathies we can have changes, this doesn’t necessarily describe their
pain.” Expert 13
 “I don’t send for imaging, if they have imaging I think where it is most helpful is when you have negative
imaging.” Expert 2

Common differential diagnosis

Key points: Related quotes in response to questions regarding differential diagnosis:

 Screen for other musculoskeletal structures that may  “Peri-neural irritation of the sciatic nerve. You often get a different response to load (e.g. you won’t get a load
refer to the region dependent increase in pain, so sometimes it might be affected by faster activities in an unloaded situation.”
 Sciatic nerve pathology is a common differential Expert 11
diagnosis  “As you know the big differential diagnosis is sciatic neuritis and um, sometimes the only difference with a whole
history and examination has been these subtle changes in the pain site - when you really break it down.” Expert
13

PHT: proximal hamstring tendinopathy.

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A.M. Nasser, T. Pizzari, A. Grimaldi et al. Physical Therapy in Sport 48 (2021) 67e75

3.5. Contributing factors 3.10. Exercise

As part of the physical examination, all experts screened pa- 3.10.1. Targeted hamstring rehabilitation
tients for contributing factors they believed relevant to the devel- All respondents prescribed targeted exercises to load the
opment of the condition. Examples included load capacity tests of hamstring musculotendon unit from early to late-stage manage-
hip and knee movements (e.g. hip extension strength and knee ment (Fig. 2). Exercises were progressed from low-load exercises in
flexion strength), calf endurance capacity tests, and range of motion positions of minimal hip flexion (e.g. isometric long lever bridge or
of the hip, knee, ankle and first metatarsophalangeal joint. supine plank) to high load exercises, depending on factors, such as
There was a consistent theme that analysing performance “on- individual pain response to the exercise. Exercises were advanced
field” was vital. “There are times where we really need to get a better as early as tolerated, which was determined primarily by pain
idea of what has actually created this within their playing environ- response to load (e.g. 24-hours post). Experts reported athletes
ment and we can do things, often to address this” (Expert 13). could often tolerate heavy load, performed slowly, early on (e.g.
Commonly observed features of gait in runners with PHT were single leg prone hamstring curl, long lever hip bridge). Key char-
overstriding, low cadence, sitting low (crouching type gait) and acteristics of exercise selection, shared by experts, included that
excessive anterior pelvic tilt. initial exercises were in near-neutral hip flexion and were per-
formed unilaterally as early as possible.
3.6. Imaging
3.10.2. Kinetic chain rehabilitation
Experts rarely used imaging to diagnose PHT, preferring to use Increasing capacity of the entire kinetic chain to improve load
information gained in the patient interview and physical exami- distribution was a recurring theme. Other areas targeted in reha-
nation. Experts usually referred for imaging when they believed a bilitation were based on individual assessment, and were often
different condition was masquerading as a tendinopathy, or when specific to goals and deficits. Deficits targeted were often related to
the condition was unresponsive to management. Absence of ten- past injuries (e.g. previous ankle sprain and triceps surae wasting).
dinopathic changes on imaging (MRI or ultrasound) was suggested
to be useful in helping rule the condition out. 3.10.3. Aberrant biomechanics
Movement retraining was also recommended if aspects of the
performance of a task were seen to place increased load on the
3.7. Common differential diagnosis
hamstring unit. While not exhaustive, this typically targeted i)
control of frontal plane femoro-pelvic position ii) control of sagittal
Experts highlighted that a primary differential diagnosis was
plane pelvic position (i.e. anterior/posterior tilt) iii) excessive for-
pain originating from the sciatic nerve or nerve sheath (Table 1).
ward trunk inclination iv) excessive hip flexion.
This pathology was reported to occur either concurrently with PHT
or as a separate entity. A theme was that a more widespread dis-
3.11. Mid-late stage exercise management
tribution of symptoms through the buttock and down the posterior
thigh was a common feature of sciatic nerve involvement, with the
Rehabilitation was progressed by i) increasing load ii) increasing
pain location slightly more lateral from the ischial tuberosity
speed of contraction iii) hamstring exercises in increasing ranges of
compared to PHT. Three experts highlighted that symptoms (sciatic
hip flexion and iv) increasing complexity (e.g. dynamic sports
nerve) could also be localised to the ischial region without pe-
specific drills). Experts progressed athletes into more hip flexion, in
ripheral spread. Tests used to diagnose sciatic nerve involvement
controlled environments, in a graded manner. Examples of exer-
included the slump test, performed in both lumbar flexion and
cises included step-ups, split squats, stairs and slow sled push.
extension, and the straight leg raise.
Athletes were then progressed to faster movements that
Several experts mentioned that undiagnosed systemic inflam-
required energy storage and release loads through the tendon.
matory conditions were at times present in patients referred for
Once athletes had successfully transitioned and were tolerating
treatment of PHT. Examples of systemic drivers here included
their sporting requirements in match play, strength and condi-
ankylosing spondylosis or psoriatic arthritis.
tioning exercises that required larger ranges of hip flexion, such as
deeper deadlifts, were reintroduced if deemed necessary.
3.8. Management
3.11.1. Passive interventions
The primary management options utilised were education and Passive interventions, such as manual therapy and injection
exercise (Table 2). Passive interventions were included by some therapies were not considered integral by any expert physiother-
experts, but only as an adjunct to education and exercise. apist. Most experts used massage therapy, as an adjunct, in the
early stages, as they felt it would assist in settling the tendon down
3.9. Education when it was in a reactive state. Manual therapy was also used as an
adjunct to target associated physical impairments (e.g. soft tissue
Patient education covered a variety of different elements massage to address hamstring muscle flexibility). One expert
(Table 2). The delivery was adapted to individual goals and specific mentioned they sometimes utilise shockwave therapy alongside a
limitations. “… I think empowering people and giving them like really loading program. Other expert physiotherapists didn’t use any
positive sort of self-efficacy and not only reassuring them that they’ll passive management strategies. More invasive management,
get better, but giving them the tools to get there” (Expert 2). Ten- including injection therapies and surgery were not recommended.
dinopathy specific pain education with the key message being that No expert physiotherapist referred patients on for platelet-rich
pain does not always mean harm and pain 24-h post activity could plasma injections or corticosteroid injections.
be used to judge how well the tendon had tolerated an activity. All
respondents agreed that the condition required significant reha- 3.11.2. Return to sport
bilitation time, “often a good 3e6 months in most people” (Expert 9), Athletes were often able to continue to compete in sport while
others mentioned 6e12 months. recovering through adjustment of training loads and incorporation
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Table 2
Key points and related quotes on management of proximal hamstring tendinopathy.

Education

Key points: Related quotes in response to a question regarding messages in education:

 Discuss the persistent nature of tendinopathy (not a quick fix)  “We’ll have to have a chat about what tendinopathy is - telling them that we don’t
 Provide education on low importance of tendon changes on imaging really understand where the pain is coming from, but these are our best guesses,
this is how it normally behaves and most importantly this is what we think we can do
about it … So the way I often wheel that discussion around is to start off talking about
is I’d say well if we had a weak muscle what do you think we’d do about it … well
muscles are different, you can strengthen them by doing exercise, you know these
muscles attach to tendons, and their turn over is slower, but how do you think your
body can make them stronger, and then we can have a chat about different types of
exercise.” Expert 7
 Deliver self-monitoring strategies (e.g. 24 h-rule)  “One of the things I talk about is load tolerance, so you’ve got to develop load tolerance,
 Educate that loading/strengthening is the key treatment independently, and the only way to do that is loading … And then you’d give them
some sort of framework. So ok, letting them know they can load it if it’s 5/10 that ok,
keep going as long as you recover well after 24 h, if it is more than that, or if the
recovery is longer then you’ve got to reduce what you’re doing. So, giving them a
framework, and that comes with the belief that pain is not equal to damage.” Expert 5
 Minimise compressive loads and energy storage and release loads  “At the gym - finding alternatives to those exercises or positions that are creating high
 Employ methods to reduce sitting pain amounts of compression, or combinations of compression and tension of the hamstring
 Modify high tendon loads and compressive loads tendons. Sitting - if that is a big problem it is something that we need to address … Also,
we advise them to try to share between sitting and standing, if they can get a sit/stand
desk set up. And then teaching them just basic functional load sharing things, such as
during bending and squatting, making sure they are using their knees when they are
bending.” Expert 12

Early management
Key points: Related quotes in response to questions regarding early management:

 Avoid exercises involving moderate hip flexion motion range  “Starting with a slow or static movement that is not provocative for a tendon out of
compression. So, examples would be a long leg bridge whether in pelvic hip neutral
a prone hamstring curl for either isometric or isotonic. In terms of the isotonic what I’m
looking for as well is time under tension, so we would look at a full 3 s concentric/
eccentric.” Expert 2
 Provide isolated loads to the hamstring muscular-tendon unit  “I like starting them on hamstring curls machine, or a cable machine. Something where
 Athletes can often tolerate heavy loads early in management if applied in an we can weight them up pretty heavy. Probably set them up on a plan of somewhere
isometric or as slow isotonic fashion around the range of 3 times per week of doing some kind of sets towards 4e6 reps. So,
depends where the athlete is in terms of and pain it might take them a little more time
to get them there. You might take them through 10 reps. 8 reps, 6 reps then even 4 reps.
So really heavy and really slow. 4 sets of 6 would be ideal and keep that as
maintenance.” Expert 6
 Start movement technique re-training targeting i) control of lateral pelvic posture  “So do a lot of work on controlling around the hip, in particular avoiding excessive
ii) control of anterior pelvic tilt posture iii) excessive trunk flexion iv) excessive anterior pelvic tilt, and single leg stance around the hip, with the thought patterns
hip flexion being that if you are struggling to maintain your pelvic position in single leg stance
then you might be at risk of falling into anterior pelvic tilt rather than controlling that
lumbopelvic position, which will increase the work load on the hamstring and
hamstring tendon while increasing compression.” Expert 10
 Use manual therapy as an adjunct to target physical impairments (e.g. reduce hip  “Ah, no not really, unless, no. If it was sciatic nerve then obviously, freeing up the path
extension, hamstring muscle flexibility) of the nerve, so the glutes and all of that. Hamstring tendon, no. I don’t think there is
anything that will really help besides load.” Expert 11
 “Yes, in the early stages I use a fair bit of soft tissue massage through the hamstrings.
You can do other techniques like dry needling depending on patient preference. This
would be just in the muscle belly, not the tendon. Restoring adequate hip mobility is
also important. I think performing techniques to increase and restore adequate hip
extension is important, particularly if they are hyper-lordotic.” Expert 8
 “With shockwave therapy we know that it can be effective, but there is uncertainty
whether it is different to placebo. So, I tell patients that this is an intervention that
does help some people’s pain, but the effectiveness has not been conclusively proven.
Would you like to try it? …. Some people get a good response. Aside from the loading
really, there is not much else I’d do as well as the shockwave therapy” Expert 5

Mid-to-late stage management

Key points: Related quotes in response to progressing past early management:

 Hip flexion range of motion starts in very limited motion range, and very slow,  In response to a question regarding progressing into more hip flexion ROM - “split
and is gradually progressed as tolerated squats where you can go into progressive amounts of hip flexion, and different
 Continue isolated hamstring loading using slow heavy loading amounts of compression. I really like stairs, so I can get people going up and down
 Progress to faster movements that require energy storage and release loads stairs and then as you get them going up 2 and 3 stairs at a time and really driving. So
through the tendon once a strong strength base is built really combining that tension and compression.” Expert 2
 “So that would be things like increasing range of hip thrusters, they could maybe do
some sideways sumo steps with band around their legs and carrying weights as
well. So, barbells. Getting into more and more flexion. I’ll progress from sideways to
doing forward lunges to maybe only 40 odd degrees and then gradually increase the
range from 40 at the hip and knee to 50/60/70/80/90. All progressed by how much
discomfort they are getting at the time and how much pain they are getting 24 h later
…. then low sled push, where I start really erect and then add more and more and more
hip flexion. So, it is only concentric, but we are starting to get really good loads through
(continued on next page)

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Table 2 (continued )

Education

Key points: Related quotes in response to a question regarding messages in education:

the whole kinetic chain. And that starts to give confidence to them into range. There are
some that really struggle with introducing hip flexion, so I might tend to go soft on that,
and even get to stage 3 where I’m starting to do faster stuff, but more upright. Then just
add the hip flexion as I can get it, otherwise you can be waiting forever.” Expert 13
 Biomechanics - movement technique re-training  “The mechanics would be things like over-striding, anterior pelvic tilt and landing with
a very straight knee in running, which goes with over-stride. That basically would be
the main ones and you might also get lots of trunk flexion, more so in sports. They’d be
the main ones.” Expert 5

Return to sport
Key points: Related quotes in response to assessing for readiness for return to sport:

 Assess hamstring strength and symptom response to loading tasks  Return to running e “I like to look at hand held dynamometry. I like to see that they
can do 80e90% of what the other leg is doing. We do 90/45 and 0. I also look at
glute bridges off a box. Knee 20 degrees of flexion. And then performing a single leg.
Getting to 20 with good lumbopelvic control throughout.” Expert 8
 “I would also like them to be pain free on an isometric muscle tests, and I like the supine
plank exercise as a bit of a general screen for what their load tolerance and load
capacity is like, so I like them to be able to lift one leg off, lift the other leg off, without
pain and feeling like they’ve got full control of that. I’ve usually had them doing a
walking program on the flat, so I like them to be pain free walking for at least 30 min”
Expert 12
 Most athletes return to sport with symptoms  “If they are an elite sportsman trying to keep them in the sport, but making
 Individuals in team sports can often continue to compete while recovering adjustments in other aspects of their life, to keep them playing e that seems to work
better than if I have to pull them out. I think the hardest ones seem to be the ones where
you really think that they’re current sporting loads are compromising them, and that is
where I’ve found it more difficult, where you actually have to stop them playing their
sport for a period of time, that is a little unpredictable because it varies between people,
so they are the ones that I’ve found more difficult, so I think getting patient by-in, really
good education from the start and then having a really clear progressive program of
functional steps, but also strengthening and loading steps so they’re not booming or
busting through the course of management.” Expert 3
 “Return to load, return to their sport with a manageable pain condition. So, I don’t
think it is about zero pain. I think it is about managing it. So, if you have someone
who can run, they can continue to run if they are managing that pain the next day.
Expert 11
 Strength and conditioning exercises that required larger ranges of hip flexion,  I like to see equal glute strength to hamstring strength. So, I think you might know e
such as deadlift, leg press are only reintroduced if necessary once full return to we use load cells to look at strength over the hip and over the knee. So, I like to see
sport is reached and condition is stable pretty equal strength there. So, no pain on any of the drop catches e including internal
rotation. No pain on forward lunges or arabesque. And then getting them to do, if they
are a sprinter/footballer, that they’ve done either their starts on their change of
direction, inside ball sort of work and come up pain free. Expert 13

Monitoring
Key points: Related quotes in response to monitoring:

 VISA-H is rarely used  “So, yeah, we should use the VISA-H but we don’t. We use our clinical experience and
 Self-monitoring using NRS of load-based tests (e.g. arabesque, single leg bridge) outcome measures that are more patient based.” Expert 11
 Change in sitting pain 24/hours post sport/activity  “So, we are looking at the level of discomfort after games. This is the main focus. Then
 Isometric strength e knee flexion dynamometry the duration of those symptoms. So, if we play on a Saturday and then generally we get
 TAMPA scale, psychological readiness for sport home by the Monday and they’ve still got relatively low levels of symptoms, say 3e4/
10 on single leg bridge, ongoing pain with sitting and that generally feeling of tightness
when they are walking, we start to worry that that is starting to linger in terms of
symptoms.” Expert 10

Preventing recurrence of PHT

Key points: Related quotes in response to preventing recurrence:

 Running technique  “… if they have a history of other conditions, so they if they have a history of ankle
sprains, or say if they’d had an ACL reconstruction then you’d need to work out
what part of the kinetic chain is vulnerable to losing strength and making sure they
remain strong.” Expert 11
 Strength training for the kinetic chain (gluteus maximus and triceps surae)  “Running, so how they run. Changing their technique so they land under their centre of
mass. That also might be an important consideration.” Expert 4
 Hamstring strength  “I would say people have to have sufficient strength and kinetic chain strength, and
then have tendon loading that’s really consistent and that’s your best way of
preventing it.” Expert 2
 Education regarding load management  “Education about changes to load, about … some of these people are trying to prepare
for a race and they get through the race, then they have time off and then they don’t
keep up any management strategies.” Expert 3
 If they are not appropriately spreading those higher load days, I think they are much
more likely to get recurrence … And then of course just activity e so what type of
activity they are doing. There are certain sports or activities that will just be higher
load or have higher compressive load and higher combinations of compressive and
tensile load for the individual” Expert 12

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Table 2 (continued )

Education

Key points: Related quotes in response to a question regarding messages in education:

 “I think improving them with specific retraining to the tasks they want to do with
progressive overload you’ll get them to the point where they can take that load. I
think that is how you prevent reoccurrence.” Expert 6

AN: Anthony Nasser (interviewer), EP: Expert physiotherapist, NRS: numerical rating scale, PHT: proximal hamstring tendinopathy, VISA-H: Victorian Institute of Sport e
proximal hamstring tendon.

strength in the hamstring and kinetic chain was echoed across

respondents, as well as addressing areas that were vulnerable to
atrophy, such as deficits associated with past injuries. “I would say
people have to have sufficient strength and kinetic chain strength, and
then have tendon loading that’s really consistent and that’s your best
way of prevention” (Expert 2). “So, getting a program that targets
lumbar spine, lower glute, hamstring strength, adductors, so all of
those exercises you just need to make sure that they continue them
forever more, basically” (Expert 9). Re-testing key objective mea-
sures, such as strength with hand-held dynamometry or in gym-
based exercises, following breaks from sport, was seen as impor-
tant since a spike in workload upon sport resumption could cause a
recurrence.

4. Discussion

We aimed to explore and summarise expert physiotherapists’

clinical reasoning around assessment, management and prevention
of PHT. Diagnosis was typically made by combining information
gained in the history and confirmed with multiple pain provocation
Fig. 2. The flow chart illustrates considerations in exercise selection during early stage tests. Proximal hamstring tendinopathy was primarily managed
management.
through patient education and progressive load-based rehabilita-
tion, targeting the hamstring unit and kinetic chain. This involved
of targeted strength and conditioning interventions. “It is pretty rare avoiding activities in positions of end range hip flexion early in
that we stop someone all together” (Expert 9). A major theme was rehabilitation and a graded return to sport. Prevention measures
that due to the nature of competitive sport, return was often rushed involved maintenance of hamstring and kinetic chain strength-
and rehabilitation incomplete. A notable exception to those views ening programs and control of physical workload.
were for track and field athletes and amateur runners who had
deconditioned significantly and did not have a history of strength 4.1. Diagnosis
and conditioning training e these often-required time away from
sport to recover. Whilst there is consensus that tendinopathy is a clinical diag-
nosis (Scott et al., 2019), there is no consensus regarding which
diagnostic tests should be used when diagnosing PHT. This is
3.12. Monitoring
supported by a systematic review demonstrating inconsistencies in
participant selection criteria (Nasser et al., 2020). Three evidence-
Most experts were aware of the Victorian Institute of Sport
based pain provocation tests e Puranen-Orava, bent-knee stretch,
Assessment - Proximal.
modified bent-knee stretch, have moderate to high sensitivity
Hamstring Tendon (VISA-H), a PHT specific questionnaire, but
(0.76e0.89) and specificity (0.82e0.91) in detecting MRI defined
rarely used it. They found the questionnaire not very responsive to
tendinopathy in symptomatic participants compared to health
change. Question-based monitoring of specific patient issues and
controls (Cacchio et al., 2012). These tests were only used by a small
provocative loading tests (Table 2) were used to monitor
percentage (23%) of physiotherapists interviewed. Most used a
rehabilitation.
number of other provocation tests, that have yet to be validated e
isometric knee flexion in supine with 90 degrees of hip flexion and
3.13. Prognosis the arabesque.
Expert physiotherapists suggested clinicians must be wary
Several experts stated that sitting pain, a common feature of when interpreting imaging findings due to the disparity between
PHT, often took over a year to resolve and lagged behind return to tendon changes on imaging and symptoms. The evidence suggests
function. Patients with concurrent pathology, comorbidities and that there is a high prevalence of MRI defined structural changes in
athletes in mid-season were reported to be more difficult to the proximal tendon in the asymptomatic population e e.g. 65%
manage with delayed recovery. (Thompson et al., 2017) and 90% (mean age not reported) (De Smet
et al., 2012) of those imaged. This theme aligned with a recent In-
3.14. Preventing recurrence ternational Consensus, reporting that imaging is not necessary
when diagnosing tendinopathy (Scott et al., 2019).
The rationale for ongoing management was reiterated due to the The relationship between PHT and the sciatic nerve, highlighted
high potential for recurrence. In particular, the importance of in this study, has long been acknowledged. Surgeons frequently
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A.M. Nasser, T. Pizzari, A. Grimaldi et al. Physical Therapy in Sport 48 (2021) 67e75

perform debridement of the nerve in conjunction with treatment of Source of funding

the affected proximal tendon (Benazzo et al., 2013; Lempainen
et al., 2009b; Young et al., 2008). The anatomical proximity has None.
been considered a reason for the relationship between these two
conditions (Martin et al., 2018), with theories including swelling of Acknowledgements
the hamstring tendon causing direct compression on the sciatic
nerve, and the sciatic nerve becoming impinged during activities None of the authors has any conflict of interest nor any financial
due to adhesions forming between the two structures (Benazzo relationships with any sponsoring organization.
et al., 2013; Hernando et al., 2015; Lempainen et al., 2015). Due to
the uncertainty expressed around diagnosis of sciatic nerve pa- Appendix A. Supplementary data
thology, future research into diagnosis is required.
Supplementary data to this article can be found online at
4.2. Management https://doi.org/10.1016/j.ptsp.2020.12.008.

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