This case report discusses the management of bilateral proximal hamstring tendinopathy in a 41-year-old ultramarathon runner utilizing isoinertial functional exercises. The treatment, which included progressive trunk stability and eccentric exercises, resulted in significant pain reduction, improved hamstring strength, and a return to competitive running. Ultrasound evaluations showed tendon healing and the patient was able to increase running distance without pain.

1. THE MANAGEMENT OF BILATERAL PROXIMAL HAMSTRING
TENDINOPATHY IN ULTRAMARATHON RUNNER
WITH ISOINERTIAL FUNCTIONAL EXERCISES:
A CASE REPORT
Giacomo Quaglia, Luca Stefanini, Maurizio Giacchino, Stefano Ventura, Angelo Cacchio, Davide Dardanello
Giacomo Quaglia PT
info@giacomoquaglia.it

2. INTRODUCTION
INJURY
Semimembranosus and biceps femuris muscles combine
to create a common tendon that insert medially in the
ischial tuberosity.
Overuse
Poor lumbo-pelvic motor control
Weakness in hamstring muscles
What the proximal hamstring tendinopathy (PHT) is?
Goom TS, et Al., J Orthop Sports Phys Ther. 2016
Rio E. et Al., Br J Sports Med 2015
Cook JL, et Al., Br J Sports Med 2016
Cook JL, et Al., Br J Sports Med 2015

3. Isoinertial machine
Huge load for tendons
Eccentric strengthening
Tendons are highly responsive to increased mechanical loading and adapt
through changes of their mechanical, material, and morphological
properties.
Bohm S. et Al. , Sports Medicine Open. 2015
INTRODUCTION
Tesch Per A. et Al., Frontiers in physiologhy, 2017

4. INTRODUCTION
Research supporting the use of
isoinertial technology is lacking
Present researches have
low level of evidence

5. OBJECTIVES
Find a way to increase mechanical loading in common
tendon
Present exercices which functionally reproduce the
running act

6. CASE PRESENTATION
•41 year-old healthy male, who had been partecipating in ultra-
endurance runs for 10 years
•Insidious onset of bilateral deep buttock pain which started 7 months
(March 2016) prior our clinical evaluation (December 2016)
•Pain exacerbated with:
Running: his pain prevents him from running from August 2016
Sitting on hard surfaces
Analytical hamstring contraction
Forward bending on the trunk with extended knees
•Musculoskeletal ultrasound showed «bilateral insertional enthesopathy
of hamstring with focal lesion on right leg».

7. CASE PRESENTATION
•Physical examination (day 0)
Pain in palpation of the tendons and bellies hamstring’s muscle
Pain with all the maneuvers that put stress in hamstrings’ structures
(bent-knee test, Puranen-Orava test).
NPRS left = 2,5/10
right = 7/10
NPRS left = 2,5/10
right = 7/10

8. CASE PRESENTATION
Pain in execution of MVIC of hamstring in prone position
SLR test left/right -, Slump test left/right -
No pain-relation with lumbar motion
MVIC in 90° knee flexion
NPRS left = 3/10
right = 5/10
MVIC first evaluation’ values aren’t available because of
the patient pain.

9. METHODS
Musculoskeletal ultrasound report
NRPS during the MVIC
NPRS during running
Running distance without pain
VISA-H questionnaire values
Cacchio A, et Al., Development and validation of a new VISA questionnaire (VISA-H) for patients with proximal
hamstring tendinopathy. Br J Sports Med. 2014.
Maximal Voluntary Isometric Contraction (MVIC) test at 90°knee of flexion
with Hand-Held Dynamometer
Hamstring’s strength (N) during MVIC at 90°knee of flexion
Seongh-Gil K. et Al., The intra- and inter-rater reliabilities of lower extremity muscle strength assessment of
healthy adults using a hand held dynamometer, J. Phys. Ther. Sci., 2015

10. INTERVENTION
In upright running, which can be a key aggravating factor in athletic
populations, the hamstrings eccentrically decelerate knee extension in
terminal swing phase.
Goom TS et Al., J Orthop Sports Phys Ther. 2016
Ascertained this, we use isoinertial machine for the possibilities to join:
1. Eccentric training reproducing the swing phase of run
2. Increase mechanical loading to common tendon

11. INTERVENTION
Timeline
FIRST
EVALUATION
(Weeks 1 to 3) (Weeks 3 to 12)
Phase I Phase II

12. INTERVENTION
(Weeks 1 to 3)
(Weeks 3 to 12)
Education of patient, respect of pain, progressive
trunk stabilty exercices, lumbo-pelvic motor control
exercices.
Introduction of eccentric exercices performed by
isoinertial machine
Phase I
Phase II

13. INTERVENTION
We proposed eccentric exercises which reproduce faithfully the functional
act of running, with the purpose of acting mainly in the proximal hamstring
segment.
1. 2.
Figure 1.,2. – Progression of an exercise performed by isoinertial machine in supine position

14. INTERVENTION

15. RESULTS

16. LIMITATIONS
«The major advantage
of case reporting is
probably its ability to
detect novities»
Trygve Nissen and Rolf Wynn, BMC Research Notes, 2014

17. CONCLUSIONS
Body functions & structures
(impairment)
Activities
(limitations)
Participation
(restriction)
&
 Tendons healing shown by ultrasound
 Reduction of pain in hamstrings’
strenght evaluation
 Significative amelioration of
hamstrings’ strenght values (N)
 Significative reduction of pain in run
 Increasment of running distance
without any pain
 Significative amilioration of VISA-H
values
 Return to high-level competions

18. 31/10/2017

19. Thanks