VCOM Louisiana Research Day Program

Clinical & Case Studies

Jana Hermoso, BSA, OMS-III; Gabriel Bailey, BS, OMS-III; Kenneth Bhatti, MS, OMS-III; Jason Sneed, DO Edward Via College of Osteopathic Medicine-Louisiana 18 OSTEOPATHIC APPROACH TO PROXIMAL HAMSTRING TENDINOPATHY-RELATED SCIATIC NERVE ENTRAPMENT (PHTRSNE)

Context/Impact: Proximal Hamstring Tendinopathy (PHT) provides a challenging diagnosis for clinicians due to limited evidence based research. Presenting as chronic pain originating at the ischial tuberosity, PHT can progress to sciatic nerve impingement, resulting in Proximal Hamstring Tendinopathy-related Sciatic Nerve Entrapment (PHTrSNE). This case expands the understanding of PHT by describing the osteopathic assessment of a runner with PHTrSNE. Report of Case: 24-year-old female marathoner presented with left hamstring pain and weakness accompanied by lower leg circumduction, or “leg whip”, accentuated by running. Pain was constantly dull. Prolonged sitting and intense running elicited sharp pain radiating from her lower glutes to mid-hamstrings. On exam, the patient had ischial tuberosity tenderness, pelvic sacral dysfunctions, decreased hip extension, and positive findings for the straight leg raise (SLR), bent-knee and Puranen-Orava tests. Evaluation with EMG/NCS showed mild chronic denervation of the left tibialis anterior muscle. PHTrSNE rehabilitation included six months of physical therapy and osteopathic manipulative treatment (OMT). Activities inducing greater hip flexion, such as speed training and uphill running, were avoided and mileage was

reduced. Post-rehabilitation, the patient reported minimal to absent pain and improved hamstring strength, stability, and running efficiency. The patient still experiences a slight circumduction while running. Comments/Conclusion: Patients with PHT present with pain originating at the hamstring tendon’s origin on the ischial tuberosity. Symptoms include pain aggravated by sitting and high impact activities, hamstring weakness, stiffness, and restriction in hip extension. [4] Provocative tests such as the Puranen-Orava and bent-knee tests, which place increased tension at the hamstring tendon, are also positive in PHT. [1,2,4,5,6] Hamstring injury is attributed to lower hamstring: quadricep ratio, hamstring stiffness, previous hamstring injuries, and insufficiently warming up. [6] Movements inducing greater hip flexion, such as uphill running and overstriding, subject the hamstring tendon to greater tension, placing increased storage loads at the hamstring origin. [4] Recurring forces to this area result in the collagenous breakdown, inflammation, thickening and degeneration of the hamstring tendon. [2] [4] This patient’s inadequate recovery and predisposition to hamstring injury facilitated this fibrotic process. Her sciatic symptoms and positive SLR indicated impingement

of the sciatic nerve. Uniquely, this patient’s PHTrSNE presented as lower leg circumduction accentuated by running. Prolonged sciatic nerve compression may have dampened motor innervation, resulting in her “leg whip”. While conventional PHT management comprises of physical and supportive therapies, this patient received osteopathic manipulative treatment (OMT). This treatment included muscle energy and myofascial release to correct leg circumduction, restore axial alignment, and reduce pain. The role OMT played in this patient’s recovery is uncertain and additional research is needed.

31 2023 Via Research Recognition Day