Ultrasound-Guided Cortisone Injections for Proximal Hamstring Tendinopathy

 

Introduction

Proximal hamstring tendinopathy (PHT) is a degenerative condition affecting the tendons of the hamstring muscles where they attach to the ischial tuberosity of the pelvis. It is a common cause of deep buttock pain that worsens with prolonged sitting, running, or repetitive hip flexion movements.

PHT is frequently seen in athletes, long-distance runners, and individuals involved in activities requiring explosive lower-limb movements. However, it can also affect sedentary individuals who engage in prolonged sitting or sudden increases in physical activity.

Ultrasound-guided cortisone injections are one of the treatment options considered for managing persistent pain and inflammation associated with PHT. This blog provides a detailed overview of proximal hamstring tendinopathy, including its anatomy, pathology, symptoms, diagnosis, and management options, with a focus on the role of cortisone injections in symptom relief.



Anatomy of the Proximal Hamstring Tendons

The hamstring muscles are a group of three muscles located at the back of the thigh:

  • Biceps femoris (long and short head)
  • Semitendinosus
  • Semimembranosus

These muscles originate from the ischial tuberosity (the bony prominence of the pelvis) and extend down to insert onto the tibia and fibula, facilitating knee flexion and hip extension.

Key Anatomical Structures Involved in PHT

  • Proximal Hamstring Tendons – The thickened fibrous structures attaching the hamstring muscles to the ischial tuberosity.
  • Ischial Tuberosity – The bony structure at the base of the pelvis where the hamstring tendons originate.
  • Sciatic Nerve – Located near the hamstring tendons, which can be irritated in severe cases of PHT.

Excessive loading, overuse, or repetitive strain can lead to tendon degeneration, resulting in proximal hamstring tendinopathy.

Pathology of Proximal Hamstring Tendinopathy

PHT is a chronic overuse injury primarily caused by degeneration rather than acute inflammation. The condition is linked to failed healing responses within the tendon structure.

Stages of Tendon Pathology

  1. Reactive Tendinopathy – The tendon thickens in response to excessive loading.
  2. Tendon Disrepair – Collagen fibres within the tendon start to break down, reducing elasticity and function.
  3. Degenerative Tendinopathy – The tendon structure becomes disrupted, leading to persistent pain, weakness, and reduced function.

Over time, small microtears within the tendon may accumulate, further weakening the tissue and reducing its ability to withstand stress.

Symptoms of Proximal Hamstring Tendinopathy

  • Deep buttock pain, particularly when sitting for long periods.
  • Pain during running, sprinting, or explosive lower-limb movements.
  • Discomfort with hip flexion, such as bending forward or climbing stairs.
  • Gradual onset of pain, which worsens over time if left untreated.
  • Tenderness on palpation of the ischial tuberosity.

Pain often worsens with increased activity levels, particularly when loading the hamstring tendons in a lengthened position.

Diagnosis of Proximal Hamstring Tendinopathy

Clinical Examination

A clinician may assess for PHT through:

  • Hamstring stretch tests – Pain may be provoked when the hip is flexed with the knee extended.
  • Palpation of the ischial tuberosity – Local tenderness may indicate tendon involvement.
  • The Bent-Knee Stretch Test – Reproduces symptoms by stretching the hamstrings in a flexed hip position.

Imaging Studies

  • Ultrasound – Can identify thickened tendons, collagen disruption, and neovascularisation (abnormal blood vessel growth within the tendon).

Management of Proximal Hamstring Tendinopathy

Conservative Treatment

  • Activity Modification – Avoiding excessive sitting or activities that aggravate symptoms.

If symptoms persist despite conservative management, ultrasound-guided cortisone injections may be considered.

Ultrasound-Guided Cortisone Injections for Proximal Hamstring Tendinopathy

What Are Cortisone Injections?

Cortisone is a potent anti-inflammatory steroid used to target inflammation and reduce pain in musculoskeletal conditions.

Why Use Ultrasound Guidance?

  • Ensures precise injection placement into the affected tendon region.
  • Reduces the risk of injecting nearby structures such as the sciatic nerve.
  • Improves accuracy and treatment effectiveness.

Procedure

  1. The clinician applies ultrasound imaging to locate the proximal hamstring tendons.
  2. The skin is cleaned, and a local anaesthetic is administered.
  3. A fine needle is inserted under ultrasound guidance into the affected tendon region.
  4. A mixture of cortisone and local anaesthetic is injected.

Patients are advised to avoid strenuous activities for a short period post-injection to allow the tendon to recover.

Mechanism of Action of Cortisone Injections

Cortisone works by:

  • Reducing inflammation within the tendon.
  • Inhibiting pro-inflammatory mediators, decreasing pain.
  • Suppressing immune responses that contribute to chronic inflammation.

This helps manage symptoms, allowing individuals to engage in rehabilitation and tendon-strengthening exercises.

Benefits of Cortisone Injections for Proximal Hamstring Tendinopathy

  • Provides targeted pain relief for deep buttock pain.
  • Minimally invasive and does not require surgery.
  • Allows individuals to engage in physiotherapy more effectively.

While cortisone injections do not reverse tendon degeneration, they can be part of a comprehensive treatment plan to help manage symptoms.

Conclusion

Proximal Hamstring Tendinopathy can cause persistent deep buttock pain, particularly in individuals who engage in running, prolonged sitting, or repetitive hip flexion movements. While conservative treatment is often effective, ultrasound-guided cortisone injections may be considered for individuals with persistent symptoms.

At Alton Pain Clinic, clinicians provide precise, ultrasound-guided injections to help manage hamstring-related pain and support rehabilitation. If you are experiencing persistent buttock pain or difficulty with movement, a consultation may help determine the most suitable treatment approach.

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