Hamstring Tendinopathy

For Medical Students

What It Tests

The hamstring tendons cross the back of the knee: the medial group inserting below the medial joint line and the biceps femoris laterally to the fibular head. 2.10.5 covers the biceps.

Examining them tests for tendinopathy at or near those insertions, which presents as posterior or posteromedial knee pain that is frequently attributed to the joint. 4.6.9 covers posterior palpation.

They matter in a knee examination because the back of the knee is the part most often not examined, and these are among the findings that live there. 4.6.9 covers that argument.

How It Is Performed

With the patient prone or with the knee flexed, palpate the medial hamstring tendons as they pass behind the medial side of the knee to their insertions. 4.6.9 covers the technique.

Palpate the biceps femoris laterally and follow it to the fibular head, noting that the iliotibial band lies adjacent and is a separate structure. 4.6.8 covers the fibular head.

Ask the patient to flex the knee against resistance and note whether that reproduces the pain, which localises it to the hamstrings.

Repeat with the knee in different flexion angles, since a tendon's tenderness changes with tension. 4.6.6 covers tendon tenderness.

Assess the joint line and the posterior joint line separately, because a posterior horn tear produces pain in the same region. 4.6.4 covers joint line tenderness.

What a Positive Means

Tenderness along a hamstring tendon with painful resisted flexion indicates a hamstring problem rather than a joint one.

Tenderness at the medial insertion below the joint line, with a normal joint line, points at the medial hamstrings or the pes insertion. 4.16.7 covers the pes.

Tenderness at the fibular head insertion raises the biceps and, with an injury history, a corner problem, and the nerve is examined. 4.6.8 covers that argument.

Posterior joint line tenderness with a normal hamstring examination points at the meniscus instead. 4.6.9 covers that separation.

Tenderness at the ischial origin rather than near the knee is a proximal hamstring problem and belongs to a different examination. 4.2.15 covers referred pain.

MRCS Level

How It Is Performed

In a viva this is a good answer to posterior knee pain with a normal joint, and the resisted flexion is the localising step.

The expected points are the prone or flexed position, the palpation of the medial group and the biceps separately, the resisted flexion, the different flexion angles, and the separate assessment of the joint line.

Say that you would examine the posterior joint line separately, since a posterior horn tear is the main alternative. 4.6.4 covers it.

Say that you would examine the popliteal fossa, since a cyst and a mass both present as posterior knee pain. 4.6.10 covers it.

Say that you would assess the hamstring flexibility and the lumbar spine, since both contribute to posterior thigh and knee symptoms. 4.1.4 covers the structured approach.

What a Positive Means

The reasoning expected is that a tendon's pain is reproduced by loading it, so resisted flexion separates a hamstring source from a joint source in the same region. 4.6.6 covers tendon tenderness.

The medial hamstrings and the pes anserinus insert close together, which is why their tenderness overlaps and why the pes is a separate page. 4.16.7 covers it.

The biceps femoris inserts into the fibular head alongside the lateral collateral ligament, which is why tenderness there has a wider differential and why the nerve is examined. 2.10.6 covers the nerve.

The hamstrings also act as a dynamic restraint to anterior tibial translation, which is why they are relevant in a cruciate deficient knee beyond their own pathology. 4.11.3 covers a test built on muscle action.

How Good It Is

The examination localises a hamstring problem reasonably well when the resisted flexion reproduces the pain, and poorly when it does not.

The tendons are harder to reach than the anterior structures, so the palpation is less precise than at the patella. 4.6.5 covers that contrast.

It cannot separate tendinopathy from a partial tear, which imaging does, and in the hamstrings that distinction matters for return to sport. 4.1.6 covers that relationship.

Its main value is excluding the joint as the source in a patient with posterior pain, which is a real contribution. 4.6.9 covers the examination it belongs to.

No figures appear for any accuracy comparison on this page, under decision 023, and the comparison is the claim being made.

FRCS Level

How Good It Is

At decision level this diagnosis is a non surgical one, and the examination's contribution is keeping the knee out of an arthroscopy.

A patient with posterior pain, a normal joint and a painful resisted flexion has a hamstring problem managed by load, and investigating the joint adds nothing. 4.6.9 covers the examination.

A patient with biceps tenderness at the fibular head and an injury history needs the corner assessed, which is a different and more consequential pathway. 4.13.4 covers it.

An athlete with a hamstring problem has a return to sport decision that rests on strength and function rather than on the knee, and the functional tests are the assessment. 4.21.7 covers return to sport testing.

In a knee with a previous hamstring graft harvest the tendons are altered, and posterior or medial pain after a reconstruction may be donor site related. 4.20.1 covers that assessment.

Where It Misleads

The commonest error is not examining the back of the knee at all.

The second is attributing posterior pain to the meniscus without a resisted flexion test.

The third is confusing the biceps with the iliotibial band laterally.

The fourth is missing a corner problem in a patient tender at the fibular head after an injury. 4.6.8 covers it.

The fifth is attributing medial pain below the joint line to the joint when the pes is tender. 4.16.7 covers it.

Fellowship Level

Where It Misleads

In referred practice hamstring problems around the knee are usually the explanation for posterior pain that has been investigated as meniscal.

A patient with a normal arthroscopy and persisting posteromedial pain, tender along the medial hamstrings with painful resisted flexion, had an extra-articular problem. 4.6.9 covers the examination.

A patient with pain after a hamstring graft harvest has donor site symptoms, which are common, usually self limiting and not a failure of the reconstruction. 4.20.1 covers that assessment.

A patient with biceps tenderness and a partially recovered nerve palsy after corner surgery has two findings in the same place, and separating them requires the operation note. 4.13.4 covers the corner.

An athlete with recurrent hamstring problems and a cruciate deficient knee may be loading the hamstrings as a substitute restraint, which is a mechanical explanation rather than a coincidence. 4.11.3 covers that mechanism.

In medicolegal work a hamstring tendinopathy is an overload condition and is difficult to attribute to a single event. 4.23.7 covers that setting.