Hi guys! I thought it would be worth making a video about conditions that can masquerade
as high hamstring tendinopathy, because it's such a difficult condition to properly diagnose,
and often people will carry on with months and months and months of failed rehab
without questioning their diagnosis. So, it's really useful to know that there are other things
that you can be thinking of and that should be excluded.
So, for those of you who don't know me, my name is Maryke. I'm one of the physiotherapists from
sports-injury-physio.com, where you can get online physiotherapy assessment as well as treatment of
your injuries. Have a look at the Description of this video if you want a link to our website.
Okay, so by masquerading I mean what conditions can give you exactly the same symptoms,
act in pretty much a similar way as a high hamstring tendinopathy? And if you're not
sure what a high hamstring tendinopathy is, I'll put a link in this video so that you can have a look at
the other videos I made about it. But basically, it gives you pain around your sit bone. And it's
very painful to sit on. Also, running and walking and things like that can be painful to do.
Now, some high hamstring tendinopathies can also cause irritation of the sciatic nerve; so,
that can muddy the waters a little bit. So, you can have symptoms down the leg, but you can also
just have symptoms to the knee. So … And I’ve had a few patients who's had symptoms into their bum;
quite often actually the glutes get irritated when the high hamstring tendon is sore as well.
But I'm going to take you through a series of different things that can give very similar
symptoms to these. And then, at the end, I'm going to explain to you
when is it useful to start looking for answers with regards to your diagnosis
and how can you make sure that your diagnosis is actually correct, okay. So, the first thing is
inflammatory conditions. I thought we'd get it out of the way, because it's one of the easier ones.
So, there are certain arthritis type or autoimmune type reactions
that can cause very similar symptoms, because it can cause severe inflammation and irritation
of that enthesis – I can never say that – where the tendon attaches into the bone.
So, a few that come to mind are rheumatoid arthritis,
psoriatic arthritis – managed to say that this time. What else is there?
It's all gone out of my head; but anything that has like a autoimmune dysfunction to
it as well. So, if you've got other signs that's not been vaguely diagnosed, because some of these
autoimmune reactions, people can't put you … the docs often can't put you in a clear box for it,
but you have random things, joints that flare up and things. So, if you've not been diagnosed,
if you have other joints that are sore, that's flaring up for no reason; you wake up in the
morning with other joints and tendons and stuff also feeling sore, it's definitely worth having
a chat with your doctor and just having them do a blood test to see if your inflammatory markers and
things in your blood are up. Because if it is, then it's worth treating that at the same time
as your high hamstring tendinopathy; because I've had patients where they actually didn't improve,
because it was that inflammatory reaction. Because a normal high hamstring tendinopathy
doesn't have inflammation in it. But if you've got an inflammatory arthritis type background, that
can mimic the same. So, if you don't treat that arthritis component, then the tendinopathy doesn't
get better either, okay. So then, the second one is not really something that can masquerade, but
it can definitely heavily contribute to why you get it and why your symptoms aren't resolving that
quickly, and that's if you've used fluoroquinolone antibiotics in the last six months to a year.
Now, it's a very specific type antibiotic. And one of the most common ones that's prescribed -
especially in the USA, it seems - is Cipro. These types of antibiotics work really well because
they're really effective for a lot of bugs out there or germs out there. But they should really
be used as a last range of antibiotic if nothing else will work or you've got a serious infection.
But the problem is that doctors give them out way too easily, because they work so well,
and they are detrimental for tendon health. What the research is showing is that even just one dose
of that antibiotic can already cause you tendon symptoms, and people have reported tendon
injuries up to six months after taking the last dose. And the reason that they're affected that much
is that it stops the collagen turnover process. So, where our bodies naturally have to replace
damaged cells in all our parts of our body on a daily basis, especially if you're doing exercise;
when you take these antibiotics, they prevent your tendons from regenerating themselves,
so you're getting a cumulative breakdown. So, you may want to chat to somebody
who can advise you about how to go about your exercise programme, because it has to be a little
bit slower if you're taking fluoroquinolone antibiotics or you've recently taken them,
because within the first six months, it seems that your turnover of your collagen is affected then.
Okay, then let's get to conditions that send similar symptoms as well. The easiest one is your
lower back. Your lower back can refer pain into it, and it can do it in two ways. It can either
just refer pain into the sit bone area or that high hamstring area that's quite sharp,
and it can be quite sharp on sitting and it can be sharp with walking; it doesn't have to feel like
sciatic type pain; it can be very localised. It doesn't have to go down the leg.
The lower back, there are different structures in there that can refer pain into that area. Then
definitely, sciatica type pain. So, if you're having sciatica symptoms – so, pins and needles,
funny sensations, pain in your big toe, things like that, in your leg as well – and the pain
is referring lower than the knee, it's definitely worth thinking about the sciatic nerve and whether
this is a true high hamstring tendinopathy or whether it's actually more sciatica, or maybe a
combination of the two that needs to be treated together. So, that's something to keep in mind.
Then, your sacroiliac joint. So, that's the big … If you look at the pelvis, you've got your sacrum
and then you've got the two – I'm going to call them hip bones but they're not really hip bones,
they're iliums – kind of like butterflies on the side, and that big joint between the sacrum
and those iliums are your sacroiliac joints. And when they are tender and sore and injured,
again, they can refer pain into that sit bone. Because when you sit, the pressure on the sit bone
affects the sacroiliac joint as well, because it's an upwards pressure then on that joint. So,
that can be something that can be contributing. And especially if you have symptoms like,
when you swing your leg out of the car or you turn over at night and you get a stinging pain
in the back there, that those can be signs that the sacroiliac joint is not happy with life. The
SIJ is notoriously difficult to diagnose, and there's not one diagnostic test that we can do
in clinic to really say it is that. If eventually it becomes a high level of suspicion that it is,
then doing a diagnostic injection into the sacroiliac joint and seeing how it affects things
is usually the best way to kind of establish whether it's it is or not. But I'll explain to
you in a minute when you should start thinking about that. Then, any injury or irritation of
the gluteal muscles, so, piriformis muscle, any of the other glute muscles, the deep gluteal muscles,
they can refer pain into that area as well. So … And it can feel very similar, and often, like I
said, you can have a combination of the two, that the high hamstring’s irritating the glutes and
then the glutes irritate the hamstrings. So, it can be an awful feedback system there. So, that's
something to keep in mind. Then also, a high hamstring tear. So, I've had a few people being
diagnosed only as a high hamstring tendinopathy, but actually, if you listen to their onset of pain,
they were pretty okay, but then they had a sudden, sharp moment where the pain started
while running or while jumping, and since then it's been really, really painful. And quite often,
if you scan those people, you'll see that actually they've got a good old tear in that
high hamstring. Now, it doesn't mean you need surgery, it just means that they often need
a little bit of a gentler approach to allow that to settle as well, especially at the start of it.
So, that's something to think about. Now, I've told you about all of these different things.
What can you do to know that your diagnosis is correct? Do you need a scan immediately?
What injections do you need? Everything like that. Well, to be honest, the first step is go
and see or consult somebody who is experienced in this condition. So, you do not need a scan
immediately if you see a clinician who'll properly listen to your history of how it started, listen
to the symptoms you're experiencing, because that really explains … Those two things already
create the highest suspicion of what's going on here. Because you need to marry up how it started
plus the symptoms you're feeling plus then making the patient do some movements and things to test
to see what hurts it. You've got to marry up all three elements of that to get to the diagnosis
of high hamstring tendinopathy. It's not enough to just have pain in that area, the rest has to
fit as well, because there are very specific symptoms that makes it a higher suspicion of
the lower back maybe being the issue or the sacroiliac joint being the issue versus just
the high hamstring tendon being the issue. So, the key is to see the correct type of clinician.
Now, you may have … diagnosis of this is also not that simple. So, on that level,
that's enough to start a rehab programme if they are sure that. okay, high suspicion, high
hamstring tendinopathy. But then you want to see some results within your first four to six weeks.
So, if you get to six weeks on the rehab and you look back and you're having this thing of,
you just can't get started because it's too painful or you're forever relapsing or you've
just not really progressed compared to where you started back six weeks ago. Now remember,
this is a condition that is notorious for taking a long time to get better, but you want to see
that there are little signs that it is moving in the right direction, and your physio should
be reviewing your progress on a two-weekly basis or something like that; just casting an eye over
it to make sure that you are progressing. And it's not going to be big things,
it's going to be things … You've got to kind of decide between you and your therapist about what
are you gonna monitor, what's the most useful. Sitting is always the last thing that becomes
comfortable. So I tend to … We take note of that, but that's not the main thing.
The things like day-to-day movements, things that's more comfortable with that. Can you
do more exercise than before without the pain setting in? Things like that. So,
if you look back after six weeks and you've not really made progress, then that's time to start
thinking about further investigations, because you're not reacting as you're expected to react.
And then it's really useful to go back to either the doc you saw or the clinician you were
seeing – well, if you … hopefully you're still in contact with your physio at that point – and that
you guys just have sit and a think and a sit-down and decide, okay, what's the next step from here?
If you've just been seeing the physio, should you go and see a sports physician who can then
actually assess you as well and order the right type of scans for you? Because you've got a wide
variety of scans that can be utilised. Now, if the scan comes back and it is clear, then ... So,
there are two parts here: Not all scans show up high hamstring tendinopathy, because it depends on
the position you're in; it can also depend on the … how good the person who reads the scan
is at interpreting scans. But if your scan came back and it was clear, it didn't show anything,
and your symptoms persist despite trying the rehab for at least six weeks, there's no improvement,
then people need to investigate further. It's not okay for them to just say, “Oh no,
but you're testing positive with your physical tests” if they've not looked at the lower back
and they've not investigated the obvious things that could be contributing to those symptoms.
So yeah, that's the thing with scans, definitely. So, if they scan your high hamstring tendons and
there's no sign of tendinopathy, they have to look up, they have to look at, okay is
the sacroiliac joint the problem? Is the back a problem? And really exclude those things for you.
Let me just make sure I'm not forgetting anything.
Yeah, so actually, to just summarise that: There are loads of things that can be causing the same
symptoms, but if you see a skilled clinician, they should be able to exclude those things through
the interview that they have with you and the tests they make you do in the clinic.
It's not necessary to go for a scan immediately; you can start rehab without a scan. It's useful to
have a scan at that point, because if it does show it up, you're more likely that it is truly that.
But remember, you can also have that it shows up but it's not actually the cause of your symptoms.
So, regardless of what that scan at the beginning shows, if six weeks later you haven't really
progressed with your rehab, you've had … you can't see progress in your day-to-day activities,
then it's worth revisiting the diagnosis and just thinking, should we be looking at other things
that can be contributing to this? And definitely, if the scan comes back clear, then don't just
accept that, but maybe get a second opinion. And if you have a high suspicion of your lower
back being part of the issue, go see somebody who specialises in lower backs, because they are often
better at reading scans of lower backs and also contributing different symptoms to that area.
So, make sure you see the right specialist in the right areas if you start doubting your diagnosis.
Excellent! Hope this was useful! Let me know if you've got any questions.
But if you need more help with an injury, you're always welcome to consult one of us
via video call – link to the website is in the Description of this video. Take care!