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The differential diagnosis and conservative treatment of a distance runner with hamstring syndrome: A case study

Regina S. Bodine, SPT Rich Maas PT, DPT, OCS, COMT Missouri State University, Springfield, Missouri

BACKGROUND AND PURPOSE: Hamstring syndrome is a common condition among athletes, however is frequently misdiagnosed due to its similar presentation of posterior thigh and buttock pain commonly seen with other hamstring pathologies. The diagnostic challenges associated with this condition, make it not only difficult to identify, but to also manage using conservative physical therapy techniques.

CASE DESCRIPTION: A 47-year-old female distance runner with complaints of posterior thigh and buttock pain was diagnosed with hamstring syndrome following a comprehensive clinical examination. Her condition was managed using a multimodal conservative approach consisting of neural mobility techniques, modalities, therapeutic exercise and extensive patient education regarding activity modifications and home management strategies.

OUTCOMES: The patient participated in 8 physical therapy visits over the course of 6 weeks.  At the completion of treatment, her Modified Oswestry Disability score improved from 20% to 0% and her reported Lower Extremity Functional Scale was 80/80. She reported a pain level of 0/10 on a numerical rating scale during running and stated she had experienced a 95% overall improvement in her pain and symptoms at a moderate to heavy activity level.

DISCUSSION:  The diagnosis of hamstring syndrome was apparent within this case based upon a cluster of findings from a detailed physical examination and the exclusion of diagnoses according to the patient’s symptoms and examination findings. The conservative multimodal treatment approach implemented to manage hamstring syndrome appeared to have contributed to a successful patient outcome within this single-case design. However, the extent of current research regarding this condition remains limited. Thus, further studies are warranted in order to identify consistent diagnostic and treatment techniques which can be extrapolated to a larger population.

BACKGROUND AND PURPOSE:

Hamstring injuries are some of the most common, yet difficult to treat injuries among high-level athletes. There is a frequent rate of re-injury, as well as a recurrent presence of chronic complaints linked with these conditions. In addition, the associated diagnostic difficulties with hamstring conditions become equally hard to manage using conservative techniques, which may become potentially detrimental to one’s athletic performance.¹ Hamstring injuries are easily misdiagnosed primarily because the majority of these pathologies have a similar presentation of symptoms including, posterior thigh and buttock pain.¹

The condition of hamstring syndrome was first identified in 1988 by Puranen and Orava who stated the clinical diagnosis of this condition may be complicated due to its similarities in presentation with other common hamstring injuries.² Thus, this condition is commonly overlooked, however is not in fact extremely rare, and must be differentiated from a variety of pathologies with similar presentations.³ The differential diagnosis of this condition is solely clinical and is done according to the identification of a cluster of typical symptoms and findings. It must be differentiated from other conditions such as, piriformis syndrome, ischiogluteal bursitis, posterior femoral muscle compartment pain, hamstring muscular tears, and spinal sciatica.?  Therefore, the purpose of this case study is to discuss the diagnostic process and differentiation of hamstring syndrome in a patient with complaints of posterior thigh and buttock pain, in addition to examining the effectiveness of conservative treatment using physical therapy within an outpatient orthopedic setting.

The condition of  hamstring syndrome is classified as a form of gluteal sciatic pain, and is considered a chronic condition in which fibrotic bands become either tethered or adhered to the proximal attachment site of the hamstring musculature at the ischial tuberosity , causing an entrapment of the sciatic nerve.?  Subsequently, repetitive contraction of the hamstring musculature with activity may cause traction, mechanical compression, impingement, or overall irritation and edema to the sciatic nerve, resulting in pain and discomfort.?  This condition can also manifest due to an acute injury to this area or may develop over time due to repetitive trauma and episodes of hamstring tears and injury creating a chronic problem. It may also be preceded by recurrent episodes of low back pain or surgeries.? The literature reports this condition is characterized by pain in the buttock region, primarily over the site of the ischial tuberosity, typically radiating distally toward the popliteal region.? The pain caused by hamstring syndrome is generally associated with physical activity such as running, stretching, and sitting and is most commonly seen among high level or endurance athletes, as well as among power sprinting or jumping athletes.?? ? Pain is typically induced when the leg is forcibly driven forward as with running, sprinting, or when endurance athletes perform sudden increases of speed, significantly influencing an athlete’s ability and performance.² There are distinctive characteristics of hamstring syndrome that differentiate it from other hamstring pathologies. For example, it varies from hamstring tears in that the pain of a tear is typically more distal within the belly of the musculature and is often associated with a palpable defect. It differs from piriformis syndrome in that associated pain is typically felt deep within the buttock musculature and can be differentiated through resisted muscle and positional testing of the involved lower extremity, among others.? Thus, it is necessary to properly identify this condition in order to appropriately guide physical therapy treatment to facilitate positive patient outcomes.

PATIENT CHARACTERISTICS

A 47-year-old female was referred by her primary care physician to physical therapy with a diagnosis of left sciatica. The patient presented to the clinic with primary complaints of pain in her left gluteal area with point tenderness just lateral to the left ischial tuberosity and radiating pain down her posterior thigh. She is employed as a registered nurse in a Neonatal Intensive Care Unit (NICU).  The patient is an avid yoga participant and is an experienced marathon runner who was recently a qualifier for the Boston Marathon. She reports that she is generally very healthy, is a non-smoker, does not drink alcohol, and exercises daily. Her past medical, surgical, and family history is relatively unremarkable, reporting only a history of depression/anxiety. Her medication use includes daily Cymbalta to manage her anxiety and depression, as well as use of NSAIDS as needed. Prior to the patient’s initial physical therapy visit, previous treatment for symptoms included only a 10-day course of Prednisone prescribed by her physician, in which she reports completely resolved her pain and symptoms. However, she reports that shortly following this course of treatment, her symptoms quickly returned.  The patient denies seeking any other prior care or physical therapy treatment for this current problem.

Current condition and chief complaints:

The patient states during her subjective report, that she began noticing her symptoms approximately 6 months prior to the date of initial evaluation and that she is unable to recall a specific incident that caused her pain, however states the symptoms have been of a gradual onset and have significantly increased since this time. She describes her pain as being intermittent and “burning”, and the location of her pain and symptoms were depicted on a self-administered pain drawing localized over her left gluteal area, just lateral to her left ischial tuberosity. She also reported that her pain will occasionally radiate from her left buttock region to mid/halfway down her posterior thigh, stating that it “feels like it travels in a line down the back of my leg”. She reported her average daily pain is 2-3/10, varying up to an 8-9/10 when it is at its worst, especially with increases in running distance, speed, and overall activity level. She describes various aggravating factors including: prolonged sitting of greater than 15 minutes, increases in activity level and running, as well as stretching of the left lower extremity. She reports that her symptoms are greatly exacerbated when she is participating in yoga, of which she attributes to the increased stretching of her lower extremity. Relieving factors include ice, massage, walking, or “getting up and moving around”, sitting on a “donut” or cushion, tailor sitting, as well as sitting with her “leg tucked beneath her.” Other reported mild secondary complaints included intermittent “burning” and “achy” pain in her low back and left lateral hip.

Functional Status:

The Modified Oswestry Low Back Pain Disability Questionnaire was administered at the time of evaluation, in which the patient rated her perceived disability as 10/50 or 20% (0=no disability, 100=completely disabled). Areas of most limitation noted on this intake form included: pain limiting her ability to tolerate sitting for greater than 10 minutes, pain relieved primarily by pain medication, as well as her ability to perform more physically stressful activities. She also reported her symptoms were interfering with her work and were significantly limiting her ability to participate in her usual recreational activities as well as normal exercise routines, primarily marathon training and long distance running.

CLINICAL IMPRESSIONS

Possible Diagnostic Hypotheses

  • Lumbar Spine Dysfunction/S1-S2 Radiculopathy: reports of “burning” buttock pain radiating to the posterior thigh with secondary intermittent complaints of low back and hip pain7

  • Piriformis Syndrome: “burning “ buttock pain, which may refer to the posterior thigh to knee when more severe; generally worse with walking and sitting may decrease pain 7

  • Hamstring Syndrome: “burning pain” localized to the ischial tuberosity, stretching frequently makes symptoms worse, sitting can make pain worse, pain with increases in activity, primarily running7

  • Hamstring Tendopathy: localized pain to the ischial tuberosity near the hamstrings insertion and pain with activity, however usually no pain with sitting and usually no referred pain7

  • Posterior Compartment Syndrome:  gradual onset of pain typically seen in long distance runners with pain experienced at posterior aspect of thigh7

  • Stress fracture:  based upon patient’s age, gender, activity level, level of demand required of marathon training and increased symptoms with increased activity7

  • Ischial Bursitis: usually involves history of chronic sitting with local pain with sitting7

    • Less likely since not chronic sitting in history

  • Hip intra-articular/labral injury: participation in stressful activity, her age, complaints of increased pain with sitting and increased pain with activity; these however 7

    • Less likely since generally refers to anterior hip and groin, secondary no history of popping/clicking

  • SIJ dysfunction: pain localized to left gluteal area and can radiate into posterior thigh gender, runner7

    • Less likely since SIJ not typical for “burning” pain and symptom location is lower than the norm for SIJ

EXAMINATION

Based upon the clinical impressions of the history, a thorough basic clinical examination of the lumbar spine and hip was performed. Upon initial inspection the patient demonstrated good muscle tone with symmetrical pelvic and lower extremity alignment. The patient’s skin was intact with no visible ecchymosis, edema, or signs of trauma.

Standing trunk movements were negative except for minimal pain in her left gluteal region during active forward trunk flexion. All other gross active trunk motions were normal and without reproduction of pain.

Active unipodal plantar flexion was symmetrical with no reproduction of pain, and the SIJ ventral gapping provocation test was negative.

Passive hip flexion, abduction and adduction was symmetrical and without provocation of pain. Passive hip internal rotation and external rotation was symmetrical, however reproduced minimal pain at end range with overpressure on the left compared to the right.

A positive straight leg raise test for sciatic neural irritability was noted on the left lower extremity, with report of provocation of pain in the left gluteal region and posterior thigh, with relief of pain following plantar flexion of the left ankle during testing.

Resisted testing of the lower extremity musculature was symmetrical and 5/5 bilaterally, except for a moderate increase in the patient’s pain noted with prone resisted left knee flexion, and a minimal increase in pain with resisted muscle testing of the left peroneals and hip flexors compared to the uninvolved right. However, there was no true myotomal weakness noted.

All lower extremity gross sensory differentiation and lower extremity reflexes were symmetrical and unremarkable. Prone PA and rotational segmental testing of the lumbar vertebra was negative for pain and within normal limits.

A seated slump test was conducted with cranial initiation on left side reproducing the patient’s pain, however more tension with pain was apparent with caudal initiation on left. Negative Valsalva.

Upon palpation there was significant tenderness noted to the area just lateral to the left ischial tuberosity.  A special test diagnostic for the identification of hamstring syndrome was also completed. Resisted knee flexion with a prepositioned SLR test, which consists of supine resisted knee flexion from a position in which the hip is flexed to 90° and the knee gently extended to its limit. This test resulted in an increase in pain and reproduction of symptoms in left gluteal area, indicating possible hamstring syndrome.? An additional special test for piriformis syndrome, resisted internal rotation from a position of hip external rotation, flexion and adduction was negative.7Fulcrum test negative.7

Modified Diagnostic Hypotheses

Diagnostic hypotheses ruled out:

  • Lumbar spine dysfunction/radiculopathy: Lumbar clinical exam essentially negative. Only trunk flexion, SLR and seated slump provocative and this can be explained by potential peripheral sciatic nerve pathology.

  • Piriformis Syndrome: Special test for piriformis negative, and negative for palpation pain.

  • Hamstring tendinopathy: Ruled out secondary to pain with sitting, (+) SLR or Slump mobility sign, and palpation was positive. Presence hamstring tendonopathy would include the following, which were not observed: (-) sitting, (-) SLR and/or Slump, tenderness to palpation would likely be noted medial to nerve on ischial tuberosity.?

  • Posterior Compartment Syndrome: Unlikely- ruled out.

  • Stress fracture: Fulcrum test negative

  • Ischial bursitis: SLR and resisted knee flexion were provocative, which is atypical for ischial bursitis.7 Thus deferred palpation.

  • Hip intra-articular injury: No limitation of hip motion

  • SIJ dysfunction: SIJ test negative

Diagnostic hypotheses ruled in:

  • Hamstring Syndrome was ruled in based upon the cluster of findings correlating with this condition which included: pain/local tenderness just lateral to ischial tuberosity where sciatic nerve travels posteriorly to biceps femoris tendon, (+) pain with sitting, (+) pain with stretching of left lower extremity. (+) SLR, (+) Slump Test for neural irritability, (+) pain during prone resisted knee flexion at 70°, and painful supine resisted knee flexion with prepositioned SLR.?

However there was not an explanation for painful resisted hip flexion and peroneals, although it was only minimal provocation. Thus a re-examination was performed at the patient’s second visit, which specifically included retesting the positive resisted muscle tests of hip flexion and the peroneals with the assistance of the clinical instructor. With repositioning and isolation of only the targeted muscle group (hip flexors and peroneals) and ensuring there was no compensatory co-contraction of the hamstring musculature activated through maximal effort, no pain was elicited. Thus, this is an important clinical note to ensure proper resisted testing execution in order to promote enhanced diagnostic accuracy, particularly with ambiguous conditions such as hamstring syndrome.

 Proposed Mechanism of Onset of Symptoms

The patient’s onset of symptoms was likely due to her participation in frequent high-level activity including marathons and other endurance activities, thus subsequently resulting in repetitive stress to the proximal hamstring musculature at the attachment site on the ischial tuberosity. A very common theme in causal factors to hamstring syndrome is repeated stretching; while the individual intends to keep muscles loose and flexible, depending on the stretching pattern the sciatic nerve is often brought under repeated tension, which will lead to ischemia, loss of axonal flow and local inflammation. Both the repeated stress on the myofascial structures and the inflammation of the nerve can bring about the development of fibrotic adhesions in this area; the result will be an entrapment of the sciatic nerve. The condition will be continuously aggravated by activity including: repeatedly driving of the leg forward during running or frequent acceleration and deceleration while training or doing speed work. The repetitive contraction of the hamstring musculature during activity results in further traction, mechanical compression, and irritation or edema of the sciatic nerve resulting in pain and discomfort.?

INTERVENTIONS

Initial intervention included a detailed explanation of examination findings and patient education. Tissue protection principles were discussed, along with a brief review of the anatomy of the nervous system using pictures and models in order to assist in the patient’s understanding of her condition. The patient was instructed to avoid stretching of lower extremity in an effort to decrease further tension/irritation to sciatic nerve. It was also recommend that the patient discontinue yoga so to prevent stretching of the hip/sciatic nerve.

Suggestions were provided regarding modifications to her running form including decreasing stride length and speed in order to reduce activation of hamstrings and subsequently attempt to reduce stretch to sciatic nerve.

Treatment interventions were targeted toward the hamstring, trunk, and other lower extremity musculature.  Initial treatment on the day of her evaluation also included a trial of iontophoresis with lidocaine to the location of her pain just lateral to her ischial tuberosity, 80 mA-min Iontopatch to be worn for 4-6 hours. The patient returned following initial visit reporting an approximate 80% reduction of pain and symptoms while wearing the patch, which lasted until the next morning during her run. She reported that once she began running her symptoms returned almost immediately.

Interventions Implemented at further visits.

1. Patient education

  • Instructed patient to avoid stretching, reviewed negative effects of stretching inflamed neural tissue.

  • Encouraged patient to sit on soft surfaces and NOT on the ischial tuberosities particularly when working. i.e. possibly, to sit on wedge (forward incline) to offload the ischial tuberosities and decrease pressure in sitting.?

  • Activity Modifications: Encouraged patient to discontinue aggravating activities, suggested modifications to running form and provided suggestions of alternate activities in order to decrease activation of hamstring musculature to decrease irritation to sciatic nerve.

  •  After several more trials of provocative running, patient discontinued running and began utilizing stair climber instead at an effort to decrease hamstring activity since stair climber emphasizes engagement quadriceps and gluteus maximus.?

2. Minimal trial of modalities as needed to decrease pain and inflammation

  • Ice massage

  • Iontophoresis with Dexamethasone or Lidocaine  (Iontopatch)

3. Neural mobility flossing in the standing and supine positioning in order to “loosen” adhesions and fibrosed tissue in different positions in order to improve comfort.  Progressed nerve flossing techniques according to comfort/tolerance, beginning slowly and initiating more aggressive pain-free techniques as appropriate.?

4. Manual Therapy:

Manual pressure to tender nerve area/adhesions, with eventual applied use of “a tool” while patient concurrently moved her lower extremity through hip flexion and extension lower extremity range of motion in order to promote tissue extensibility and “break up” fibrosed tissue and adhesions.  Encouraged patient to trial self-massage at home. Initially patient utilized her fingers of both hands and she noted this was difficult and uncomfortable to her hands. She then located a “tool” from her kitchen and discovered this worked well for her and she could adequately apply the correct amount of therapeutic pressure.

5. Therapeutic Exercise: Initiated gluteal retraining, hip and core strengthening/stabilization exercises. Exercises were initiated to encourage gluteus maximus and quadriceps activation and emphasize a position that inhibited hamstring activation. This was done in an attempt to normalize normal muscle firing patterns of gluteal contraction prior to biceps femoris during hip extension.??¹?

6. Development of Home Exercise Program:  Instruction of progression through a comprehensive home program, initially of tissue protection principles and beginning with gentle, pain free ROM, neural flossing techniques, and eventual instruction in more aggressive pain-free neural flossing techniques in addition to lower extremity and trunk strengthening/stabilization drills as appropriate.

OUTCOMES

The patient was seen for eight visits over the course of a six-week period, in which the patient responded positively to treatment. There was a minor setback throughout the course of treatment, in which the patient worked three 12-hour shifts in a row in the NICU. She reported it as being the “busiest/worst weekend she has experienced at work in a long time”.  During this time, she was unable to consistently perform her home exercises and stated that she experienced a significant increase in her pain and symptoms.  Additionally, although the patient continued to have discomfort, she reported that she was continuing to participate in her marathon-training program. It was at the time of the patient’s fourth treatment session when she stated that she had reluctantly discontinued running and was modifying her fitness routine in order to reduce stress to the hamstrings.

Following the cessation of running, the patient began to have an exponential increase in her progress with significant decrease in her symptoms. At the completion of her treatment, the patient reported that she was able to tolerate prolonged sitting for greater than 2 hours without discomfort. She also reported a 95% improvement in her pain and function at a moderate activity level since the date of initial evaluation. However, she had not yet returned to her previous training regimen, but had begun to run “easy” for 4 miles without pain (0/10) in the left gluteal area. On the Modified Oswestry Low Back Pain Questionnaire the patient initially perceived her disability as a 20% (0%=no disability, 100%=completely disabled). Following eight treatment sessions, her Oswestry was a 0%. The Lower Extremity Functional Scale was 80/80 (80= no disability, 0=completely disabled). All resisted manual muscle testing was symmetrical, 5/5 and without reproduction of pain. The patient reported that she was confident with continuing her home exercise routine independently at home and progressing it as necessary. All of the patient’s established long term goals were achieved at the time physical therapy was discontinued. Overall, the patient reported “excellent” progress with therapy and attributed it to her resolution of symptoms.

DISCUSSION

The primary challenge of this case of the patient with posterior thigh and buttock pain was the initial diagnostics and the ability to accurately identify the mechanism of pain or the pain generator.? The differential diagnosis of conditions of this area has often demonstrated itself to be extremely challenging secondary to many conditions involving the hamstring having similar presentations of pain and symptoms, along with the possible aggravating structures being closely interrelated.?  Additionally, optimal treatment interventions have been debated due to the ambiguousness of these injuries, as well as patient complaints.??¹?  Interventions used in the treatment of this condition have ranged from conservative multimodal approaches including, stretching, progressive strengthening, pelvic stabilization, neural mobilization/glides, agility exercises, and manipulations, to more invasive aggressive treatment techniques including a surgical release procedure.²???¹?

It is imperative to understand hamstring syndrome as a clinical entity and be aware of the common cluster of findings that are often associated with this condition. Within this case, the patient’s condition of hamstring syndrome was based upon a cluster of findings from a detailed history and clinical examination, with an exclusion of diagnoses according to the patient’s presentation of symptoms and exam findings.  It was determined that this condition was likely chronically developed and directly related to her high level of activity, participation in endurance sports, and repetitive stretching program. The conservative treatment techniques implemented in this case that were consistent with current literature, which included the use of modalities, neural mobility exercises, soft tissue manipulations, and avoidance of stretching, contributed to the positive outcomes experienced by this patient.7

IAOM Comment: This is a classic case of hamstring syndrome that had excellent outcomes with conservative care. The IAOM-US clinical Diagnosis and Manual Therapy of the Hip course discusses hamstring syndrome at length in the Differential Diagnosis of Buttock Pain lecture. When conservative care is unsuccessful, local injections can be beneficial, and in rare instances, surgery is needed to alleviate sympto

Patient reported she was unable to apply enough manual pressure with her fingers/hand, so she discovered a tool she had in her home and was able to much easier hold that with her hand and apply significant pressure, she reports she can “feel it breaking up adhesions”  Performed technique for approximately 30 minutes 1x per day.

  • Applied gentle manual pressure using tool to tender nerve area/adhesions using this tool, while patient concurrently moves lower extremity through hip flexion and extension lower extremity range of motion in order to promote tissue extensibility and mobility in addition to “breaking up” fibrosed tissue and adhesions.

References

1.  Lempainen L., Sarimo, J., Mattila, K., Vaittinen, S., & Orava, S.  Proximal hamstring tendonopathy: results of surgical management and histopathologic findings. The American Journal of Sports Medicine, 2009; 37: 727-34.

2. Puranen, J., Orava, S. The hamstring syndrome: a new diagnosis of gluteal sciatic pain. The American Journal of Sports Medicine. 1988;16: 517-21

3. Saikku K., Vasenius J., Saar P. Entrapment of the proximal sciatic nervy by the hamstring tendon. Acta Orthop. Belg. 2010; 76: 321-324.

4. Migliorini S., Merlo M. The hamstring syndrome in endurance athletes. British Journal of Sports Medicine; 2011; 45:363

5.  Young IJ, van Riet RP, Bell SN. Surgical release for proximal hamstring syndrome. The American Journal of Sports Medicine. 2008; 36: 2372-2378.

6. Turl SE, George KP. Adverse neural tension: a factor in repetitive hamstring strain. Journal of Orthopaedic & Sports Physical Therapy. 1988; 27:16-21.

7.  Sizer PS. Phelps V, Brismee JM, vanParidon D, Matthijs O. Diagnosis-specific orthopedic management of the hip. Minneapolis, MN: OPTP; 2009

8. Lyons K., Perry J., Gronley JK, Barnes L., Antonelli D. Timing and relative intensity of hip extensor and abductor muscle action during level and stair climbing: An EMG study. Physical Therapy; 1983:63:1597-1605

9. Podschun L. Hanney WJ, Kolber MJ, Garcia A., & Rothschild, CE. Differential diagnosis of deep gluteal pain in a female runner with pelvic involvement: a case report. International Journal of Sports Physical Therapy. 2013; 8:462-471.

10. Sherry MA (2012). Evaluation and treatment of acute hamstring strains and related injuries. Sports Health. 4(2), 107-114.

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