Query hamstring tendinopathy

[Serge]

Hi there,

I am a 23M (6’4", 195 lbs) with a 12 mo history of posterior knee pain.

Been an athlete for most of my life but took time away from organized sports for the last few years. One year ago, I started playing basketball with some friends once a week on hardwood, and after my second or third game, I began to feel substantial pain in my R posterior knee. The initial pain was diffuse and ROM-independent, but after this initial stage (duration approx. one week) it became apparent that the pain was exacerbated on terminal extension, and most severely on passive terminal flexion (ie. sitting in a heel-raised squat passively).

Having reviewed available evidence, I began performing hamstring curls with a eccentric emphasis 3x/week. This resolved the pain at terminal extension relatively quickly. However, I still struggle with the pain at passive flexion. The pain also appears pronounced when absorbing impact from jumps (which relates to its presumed etiology).

Currently training (running the Bridge) and continue to perform the eccentric hamstring curls on my GPP days (2x/week). I do not experience any posterior knee pain during any of my lifts, and my progress does not appear to be curtailed by this pain.

From my clinical picture, I would put hamstring tendinopathy pretty high on the differential, given its relative response to eccentric training, lack of response to NSAIDs and prolonged nature.

My question is two-fold:
(1) Is ultrasound a worthwhile investigation? From my perspective having evidence of the tendinopathy does not change the management, and surgical intervention is likely not indicated anyway, but perhaps I’m missing something.
(2) Have you ever managed hamstring tendinopathy, and if so, what recommendations in terms of load management and exercise selection would you make?

Summary: 23M currently training, with 12 mo history of posterior knee pain. (?) hamstring tendinopathy, looking for recommendations on management to regain painless function.

Looking forward to hearing from you.

Serge

[Michael_Ray]

@Serge

Hi there,

I am a 23M (6’4", 195 lbs) with a 12 mo history of posterior knee pain.

Been an athlete for most of my life but took time away from organized sports for the last few years. One year ago, I started playing basketball with some friends once a week on hardwood, and after my second or third game, I began to feel substantial pain in my R posterior knee. The initial pain was diffuse and ROM-independent, but after this initial stage (duration approx. one week) it became apparent that the pain was exacerbated on terminal extension, and most severely on passive terminal flexion (ie. sitting in a heel-raised squat passively).

Having reviewed available evidence, I began performing hamstring curls with a eccentric emphasis 3x/week. This resolved the pain at terminal extension relatively quickly. However, I still struggle with the pain at passive flexion. The pain also appears pronounced when absorbing impact from jumps (which relates to its presumed etiology).

Currently training (running the Bridge) and continue to perform the eccentric hamstring curls on my GPP days (2x/week). I do not experience any posterior knee pain during any of my lifts, and my progress does not appear to be curtailed by this pain.

From my clinical picture, I would put hamstring tendinopathy pretty high on the differential, given its relative response to eccentric training, lack of response to NSAIDs and prolonged nature.

My question is two-fold:
(1) Is ultrasound a worthwhile investigation? From my perspective having evidence of the tendinopathy does not change the management, and surgical intervention is likely not indicated anyway, but perhaps I’m missing something.
(2) Have you ever managed hamstring tendinopathy, and if so, what recommendations in terms of load management and exercise selection would you make?

Summary: 23M currently training, with 12 mo history of posterior knee pain. (?) hamstring tendinopathy, looking for recommendations on management to regain painless function.

Looking forward to hearing from you.

Serge

Hey Serge,

Thanks for the questions. Sorry to hear about the posterior knee issue.
Regarding your questions:

1. No, ultrasound wouldn’t tell us anything meaningful or that would alter clinical course based on the information you’ve supplied thus far.
2. Hamstring tendinopathy is approached similarly as others. The typical course of action is remove dynamic loading of the area (running and jumping in your case) while dosing in load appropriate heavy slow resistance in a linear progression fashion. Sounds like you are on the right track.

What has been provocative most recently? Are you still playing basketball?
Also - during initial onset, do you recall any specific details or was it a scenario where you played basketball and then the next day had posterior knee pain?

[Serge]

Hi Michael,

Thanks for the response and the information. From my survey of the literature, I never found any tempo recommendations for the eccentric training despite the general recommendation for it (perhaps you have some insight on this). For most of the time I have been the hamstring curls, I would tend to have a 3-5 second eccentric. My most recent provocation probably came about 12h after a training session where I shortened the eccentric and worked with heavier loads - that certainly increased the soreness in the area for most of the next day or two.

I’m not playing basketball at all anymore. The Bridge is essentially my only activity other than regular activities of daily living.

Details about the onset:

1. played in second or third game, fully pain-free at that point;
2. drove home (20 mins);
3. got out of car and immediately felt stiffness and tenderness with gait. Couldn’t terminally extend or flex the knee without substantial pain. This initial pattern of pain persisted for about 3-4 days. Then the pain settled into (more or less) what it is now - although the pain has certainly gotten better with the aforementioned exercise intervention.

Thanks,
Serge

[Michael_Ray]

@Serge

Hi Michael,

Thanks for the response and the information. From my survey of the literature, I never found any tempo recommendations for the eccentric training despite the general recommendation for it (perhaps you have some insight on this). For most of the time I have been the hamstring curls, I would tend to have a 3-5 second eccentric. My most recent provocation probably came about 12h after a training session where I shortened the eccentric and worked with heavier loads - that certainly increased the soreness in the area for most of the next day or two.

I’m not playing basketball at all anymore. The Bridge is essentially my only activity other than regular activities of daily living.

Details about the onset:

1. played in second or third game, fully pain-free at that point;
2. drove home (20 mins);
3. got out of car and immediately felt stiffness and tenderness with gait. Couldn’t terminally extend or flex the knee without substantial pain. This initial pattern of pain persisted for about 3-4 days. Then the pain settled into (more or less) what it is now - although the pain has certainly gotten better with the aforementioned exercise intervention.

Thanks,
Serge

Gotcha. You’d likely benefit from a consultation with us to help guide the path back to your goals: Contact Us | Barbell Medicine

Heavy Slow Resistance is different than eccentric training in that both concentric and eccentric phases are at tempo rather than just the eccentric phase. Regarding the recent onset, likely means you loaded more than you were ready to handle (possibly from decreasing pacing of eccentric and allowing you to lift a heavier load). Glad to hear things are feeling better than they did at initial onset.