Anatomy
The 3 large thigh muscles (hamstrings, hamstrings) have muscle attachments on the ischial tuberosity (tuber ischiadicum). The hamstrings bend the knee and extend the hip.
Right gluteal muscles from behind:
A. Bursa trochanterica m. glutei maximi
B. M. gluteus maximus
C. M. biceps femoris (caput longum)
D. M. semitendinosus
E. M. semimembranosus
F. M. adductor magnus
G. M. gracilis
H. M. quadratus femoris
I. Bursa ischiadica m. glutei maximi
Cause of the problem
‘Inflammation’ (inflammation) of the tendon attachments (enthesitis) at the ischial tuberosity (tuber ischiadicum) occurs with repeated (over)exertion (running, sprinting). This causes microscopic tears in the tendon and especially at the tendon attachment. The tendonitis is a warning that the training is too strenuous for the muscle tendon in question and if the load is not reduced, a long-term condition with pain and possible rupture of the hamstring muscle attachment on the ischial tuberosity (‘fibre’) can develop, resulting in a significantly longer rehabilitation period.
In severe cases, there is a partial or total rupture/tearing of the hamstring attachment from the ischial tuberosity, which is almost always a result of long-term tendonitis due to incorrect/lack of rehabilitation. Inflammation of the bursa between the tendon attachment at the ischial tuberosity can be seen when the tendons are overloaded.
From 2015-2022, the number of hamstring injuries has doubled in professional football. 18% of all hamstring injuries are recurrences of previous injuries, the majority of which occur within 2 months (Ekstand J. et all 2023).
Symptoms
Pain high in the back of the thigh/ buttock, mainly when running (sprinting). The pain on the ischial tuberosity can sometimes extend to the back of the thigh. The pain is aggravated by pressure on the ischial tuberosity (e.g. sitting position), stretching and activation of the thigh muscles (bending the knee and stretching the hip against resistance), such as when standing on the affected leg with a healthy foot and stepping on the heel of the shoe to get the foot out of the shoe (‘Taking off shoe test’) (Reiman MP, et al. 2013).
Ruptures are characterised by sudden pain and often bleeding that can be seen on the back of the thigh.
Examination
In mild cases with minimal soreness and no discomfort during normal walking, the diagnosis is usually made on clinical examination alone. However, the severity of soreness is not always a measure of the extent of the injury. For more pronounced tenderness (suspected rupture), examination by a professional is recommended to ensure correct diagnosis and treatment. If the diagnosis is in doubt (suspected significant rupture), ultrasound and possibly an MRI scan can be performed.
Treatment
Treatment includes relief from pain-inducing activity, stretching and graduated long-term rehabilitation within the pain threshold.
If long-term rehabilitation is unsuccessful, medical treatment may be considered in the form of adrenal cortex hormone injections around the inflamed muscle tendon attachments (in the bursae) at the sit bones as part of long-term rehabilitation over several months to reduce the risk of recurrence and rupture. Of course, after a prolonged period of injury, the tendon cannot withstand maximum strain after only a short-term rehabilitation period.
Surgical treatment is usually only indicated if at least two of the three tendons that attach to the ischial tuberosity are ruptured and the distance between the tendon ends is more than 2 cm (retraction). In elite athletes with rupture of any one of the three tendons with at least 2 cm of retraction or failure to progress after 6 months of regular rehabilitation, some recommend surgery, but evidence is sparse (Allahabadi S et al. 2024). Recent studies suggest that there is no difference between rehabilitation and surgery even in total ruptures with more than 2 cm of retraction (Mafulli N., et al. 2024)
Nordic hamstring exercises (Petersen, J., et al., 2011 and van Dyk, N., et al., 2019) have been documented in several studies to prevent a significant proportion of hamstring injuries, especially. the relapses. It is therefore of great importance to continue performing the exercises regularly for a long time (1 year) after resuming sports activity.
Complications
If the progress is not smooth, you should consider whether the diagnosis is correct or if complications have arisen.
In particular, the following should be considered:
