Caring Medical - Where the world comes for ProlotherapyHamstring Injuries

Dr. David Woznica ProlotherapistDavid N. Woznica, MD

In this article we will examine the difficulties and frustrations athletes suffer with acute and chronic hamstring problems.

Before you read on, do you have a question about hamstring injuries? You can get help and information from our Caring Medical Staff

First, what are some of the different types of hamstring injuries?

Hamstring injuries are a hamstring strain/pull, a partial tear, or a complete tear. A diagnosis of chronic hamstring problems may include Tight hamstring muscle syndrome or simply hamstring syndrome.

  • Grade 1 hamstring tears are considered the mildest injury.
  • Grade 2 hamstring tear and Grade 3 hamstring tear injuries may take months to heal if they respond at all to conservative treatments. In grade 3 tear the muscle can completely pull away from the bone at the tendon attachment.

Tight hamstring muscle syndrome or simply hamstring syndrome is a complaint among some athletes. Athletes may experience gluteal sciatic pain (a pain in the bottom of the butt) from an inflammation of the sciatic nerve at the insertion site of hamstring muscles to ischial tuberosity.

Tight hamstring muscle syndrome can also be a postural abnormality seen with spondylolisthesis in athletes, which is the dislocation of a vertebra and may be referred to as disc related tight hamstring syndrome. Symptoms may include a pinching of the nerve that extends to the hamstring muscle because of the dislocation of the vertebrae.

HamstringFor someone with a chronic hamstring problem, telling them that hamstring muscle syndrome or a “pulled hamstring”  can be difficult to treat would come as no surprise.

Doctors from Northwestern University Feinberg School of Medicine recently suggested in the medical journal Orthopedics that the typical difficult to treat hamstring patient may have already been given several traditional conservative treatments, including physiotherapy and nonsteroidal anti-inflammatory drugs, which are both considered inconsistent treatments. Corticosteroid injections are frequently recommended and have demonstrated success but can adversely affect local tissues and the detrimental long-term effect of cortisone has been well documented. With these findings, doctors exploring different treatment options have found Platelet-rich plasma (PRP) has emerged as a safe, effective treatment for several orthopedic pathologies.1 We are going to discuss more research below on PRP injections as part of a comprehensive Prolotherapy program.

Hamstring Syndrome Treatment

In the Journal of strength and conditioning research, University and medical researchers in Taiwan wrote that medical treatment of hamstring muscle syndrome typically involves at least part of the RICE protocol, rest, ice, compression, and elevation. Although some of these treatment components do bring some initial pain relief from hamstring injuries. Research evidence shows that “ice application or topical cooling does not enhance and appears to delay the return to normal of muscle damage markers and subjective fatigue feeling after eccentric exercise.”2

In other words, RICE hinders the healing of muscle tissue. Even the inventor of the RICE protocol is now saying both ice applications and rest delay muscle healing.

The dangers of ice therapy have been noted for decades, in a landmark 1992 study from Duke University published in the Journal of athletic training, ice applications were shown to cause muscle damage, because of the dangers of freezing tissue. This danger could also extend to nerve damage.3

  • Hamstring stretches are another typical treatment, however, static, dynamic, passive stretching without accompanying muscle strengthening exercises can do more damage and lead to more injuries and pain problems.
  • Dutch researchers at the University Medical Center in Utrecht released their findings in early 2017 suggesting that in elite soccer players, although hamstring flexibility is thought to play a major role in preventing hamstring injuries, there is no significant relationship between hamstring flexibility and hamstring injuries.
    • Stretching does NOT prevent hamstring injuries.4

Another standard practice is the use of steroids and anti-inflammatory medications. However, side-effects of steroid injections and anti-inflammatory medications and their soft-tissue damaging properties have been well documented in the medical literature.

Let’s get back to stretching and muscle exercises that put not only the hamstring, but knee instability at risk.

biceps femoris longusDoes preventative training put your knee at greater risk?

Doctors at the University of Health and Sports in Berlin published these findings in the journal Medical hypotheses.

  • Both hamstring and ACL injuries are among the most typical injuries, particularly in a change of direction and high speed running sports. They’re also difficult to treat.
  • In the past few years, sports medicine practitioners and exercise scientists have mainly been focusing on the development and implementation of preventive programs in order to reduce the number of lower limb injuries, mainly by improving knee alignment.
  • A number of studies have been able to prove the success of these training interventions, which are mainly addressing sensorimotor abilities and plyometric activities.
  • The number of non-contact hamstring injuries has nevertheless been on the rise, particularly in sports like soccer and football.
  • The researchers introduce the hypothesis that some training interventions have a massive influence on the activation patterns in the targeted muscle group, and on the biceps femoris in particular.
  • Training-induced adaptations in hamstring activation patterns can thus lead to an increased injury susceptibility.5

Hamstring Muscle Syndrome, Buttock Pain and High Hamstring Tendinopathy – is stretching the danger?

Beyond how to stretch hamstrings – how to repair injured hamstrings: From a regenerative medicine perspective, the preferred long-term solution is to strengthen the ischial tuberosity, a point of attachment for the hamstring muscles with regenerative soft-tissue treatments such as Prolotherapy, Platelet Rich Plasma, and Stem Cell Therapy. These injection treatments stimulate repair of the buttock pain and posterior thigh pain. One way they do so is by strengthening the tendon attachments of the semitendinosus, semimembranosus, biceps femoris muscles of the hamstring.

This is attested to by the pain deep in the buttocks or upper back-side of the thigh reported by some patients and confirmed by physical examination as tendon injury near the origin of the hamstring muscle off of the ischial tuberosity. That is the name of the bone which bears body weight in the seated position. It is an injury we see in mid to long distance runners, yoga practitioners, and occasionally non-athletic individuals who have been injured by improper chiropractic adjustments or physical therapy.

  • Occasionally the damage to the tendon in chronic cases can be severe enough to cause irritation of the nearby sciatic nerve, thus producing back pain symptoms of referred pain down the entire back of the leg which is more typically associated with herniated lumbar discs.

The pain is worse when the patient is seated on a hard surface, and after running, especially at faster speeds. There can be pain at rest in severe cases.

  • The bent knee stretch test is applied for the diagnosis of this condition with the patient lying supine. The hip and knee are first maximally flexed towards the patient’s chest, and then the knee is extended gradually. Pain at the origin of the hamstring on that side which reproduces the patient’s pain is diagnostic.

Additionally, a diagnosis for injection treatments such as Prolotherapy relies on direct thumb pressure over the proximal (center) hamstring tendon in the buttocks, the so-called “jump sign” to reproduce the pain, localize the injury, and determine the best treatment. Direct firm pressure on affected areas causes the patient to “jump’ because of accentuation of the pain.

Finally, injection of a local anesthetic solution into the tendon-bone junction (enthesis) of the affected hamstring tendon can cinch the diagnosis by immediately eradicating all evidence of pain at rest or with motion or sitting.

In summary, there are several other conditions that can produce a similar symptom complex of high hamstring tendinopathy.

  • Herniated lumbar discs and sacroiliac ligament strain both refer pain into the deep buttock area.
  • Spasm of the piriformis muscle is another common condition in athletes and, in older individuals, metastatic cancer to the bone and pelvic stress fracture must also be considered.

Fortunately, all of these conditions except for the latter two will respond to appropriately applied Prolotherapy, but making the differential diagnosis is critical in order to achieve the most rapid response. When necessary, X-rays, bone scan, or MRI imaging is ordered.

Prolotherapy injections can offer the fastest route to recovery from high hamstring tendinopathy. The only possible danger from prolo for this disorder is the proximity of the hamstring tendons to the sciatic nerve, but proper experience and technique will always avert any problems in this regard. Should the nerve ever be touched by the slowly advancing prolo needle (a precautionary measure on the prolotherapist’s part), there will be a quick electrical sensation down the leg. As the needle is withdrawn or redirected, any discomfort will be mild and temporary.

Platelet Rich Plasma Therapy

Doctors from the University of Colorado School of Medicine and the Southern California Hip Institute published research in the Muscles, Tendons, Ligament Journal which cited the research surrounding the use of Platelet Rich Plasma Injections for hamstring tendinopathy.6 Here is the summary:

  • In a study from the British Journal of Sports Medicine, doctors compared PRP, platelet-poor plasma (PPP), and no injection in professional athletes with MRI-positive hamstring injuries.
    • All patients underwent a standardized rehabilitation program. Time to return to sport was found to be significantly better in the PRP group (mean 21 days) compared with the PPP group (mean 27 days). No significant difference in re-injury rate was noted between the three groups at 2 months or 6 months following intervention.7
  • In another study led by the University of Colorado Hospital Department of Orthopedic Surgery, doctors examined 18 patients with chronic proximal hamstring tendinopathy who received a single PRP injection by ultrasound guidance. Patients had chronic hamstring pain symptoms for an average of 32.6 months prior to their injection and all patients had attempted other non-surgical treatments such as cortisone injections and physical therapy prior to injection. Based on a visual analog scale (VAS) for pain, patients had an average improvement in pain of 63% at 6 months following PRP injection.8

In recent research that we cited at the beginning of this article, doctors at Northwestern University looked at 18 patients, 12 females and 6 males – average age 42.6 who had pain that lasted an average of 32 months.

  • The patients received one PRP treatment. Six months after the injection, 10/18 patients had 80% or greater improvement.

Overall, the average improvement was 63% with one patient – little to no improvement. The only documented side effect was post-injection discomfort that resolved within seventy-two hours.1

This was ONE Injection – please see my article on choosing a PRP doctor, we discuss the idea of single injection PRP treatments.

These result could not be replicated long-term in cortisone groups. In a study from Stanford University, “Fifty percent of patients had symptomatic improvement lasting longer than 1 month after percutaneous corticosteroid injection, and 24% of patients had symptom relief for more than 6 months.”8 Compare that to the PRP treated patients at Northwestern who had 80% relief.

In other words, the typical conservative treatment of cortisone is not a guaranteed cure for this hamstring injury.

What these researchers found is what Prolotherapy doctors have long known: a better approach to hamstring injury is to strengthen the fibro-osseus junction of the ischial tuberosity with Prolotherapy. The ischial tuberosity bears body weight in the seated position and is a point of attachment for the hamstring muscles. In the above research, Platelet Rich Plasma injection was used at the “muscle origin” the fibro-osseus junction.

Do you have a question about hamstring injuries? You can get help and information from our Caring Medical Staff

1. Wetzel RJ, Patel RM, Terry MA. Platelet-rich Plasma as an Effective Treatment for Proximal Hamstring Injuries. Orthopedics. 2013 Jan 1;36(1):e64-70. doi: 10.3928/01477447-20121217-20.

2.Tseng CY, Lee JP, Tsai YS, Lee SD, Kao CL, Liu TC, Lai C, Harris MB, Kuo CH. Topical cooling (icing) delays recovery from eccentric exercise-induced muscle damage. J Strength Cond Res.2013;27(5):1354-61.

3. Malone T, Engelhardt D, Kirkpatrick J, Bassett F. Nerve injury in athletes caused by cryotherapy. J Athl Train. 1992; 27(3): 235–237.

4. van Doormaal MC, van der Horst N, Backx FJ, Smits DW, Huisstede BM. No Relationship Between Hamstring Flexibility and Hamstring Injuries in Male Amateur Soccer Players. Am J Sports Med. 2017 Jan;45(1):121-126.

5 Ertelt T, Gronwald T. M. biceps femoris–A wolf in sheep’s clothing: The downside of a lower limb injury prevention training. Medical Hypotheses. 2017 Nov 1;109:119-25.

6. Fader RR, et al. Platelet-rich plasma treatment improves outcomes for chronic proximal hamstring injuries in an athletic population. Muscles, Ligaments and Tendons Journal. 2014;4(4):461–466.

7. Hamilton B, Tol JL, Almusa E, Boukarroum S, Eirale C, Farooq A, Whiteley R, Chalabi H6. Platelet-rich plasma does not enhance return to play in hamstring injuries: a randomised controlled trial. Br J Sports Med. 2015 Jul;49(14):943-50.

8. Kraeutler MJ, Garabekyan T, Mei-Dan O. The use of platelet-rich plasma to augment conservative and surgical treatment of hip and pelvic disorders. Muscles, Ligaments and Tendons Journal. 2016;6(3):410-419. [Pubmed]

8 Zissen MH, Wallace G, Stevens KJ, Fredericson M, Beaulieu CF. High hamstring tendinopathy: MRI and ultrasound imaging and therapeutic efficacy of percutaneous corticosteroid injection. AJR Am J Roentgenol. 2010 Oct;195(4):993-8. [Pubmed]


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