Proximal Hamstring Tendinopathy Secondary to Malalignment Syndrome and the Effects of Running on Cross-Sloped Surfaces: A Case Report

Background Patients with proximal hamstring tendinopathy (PHT) will typically report deep buttock or thigh pain that increases with running speed which may also flare with prolonged sitting. Malalignment refers to a minimal displacement from the normal alignment of any of the bones that results in abnormal biomechanical stresses. The effects of running on cross-sloped surfaces (i.e. cambered) involve asymmetrical forces that can predispose to malalignment. This case report serves to remind the clinician to check for pelvic malalignment early in the treatment of PHT and other common running injuries, provides recommendations for effective screening and treatment measures, and demonstrates that running on cross-sloped surfaces is involved in the development of pelvic malalignment. History A 19 year old male D1 collegiate long-distance runner initially presented with left buttock pain of 3 months duration. Over the course of the subsequent 7 years he experienced increasing pain in his right shin and tibial tuberosity, increasing soreness in his right calf, right Achilles tendinopathy, plantar fasciitis, and a left lateral ankle sprain. Physical Exam Significant Findings: -Right anterior rotated innominate -Left innominate inflare -Right leg shortened when moving from supine to sitting -Reduced ROM and flexibility on left when performing seated IT band stretch MRI of left hip: -Partial-thickness tearing at the ischial attachment of the left semimembranosus tendon Treatment and Outcomes Ineffective: -Physical therapy (hamstring strengthening, massage, EMS, LED, US, ice, heat) and Aleve -Active Release Technique and Graston -Left ischial tuberosity bursal injection with Marcaine and Methylprednisolone -1/8 inch right heel lift Effective: -Running on opposite side of road to reverse angle of cross-slope -Daily Muscle Energy treatment of left innominate inflare and right anterior innominate Conclusions Distance runners should avoid running on cross-sloped surfaces; regular reversal of direction is necessary. The seated IT band stretch may be a more suitable measure than Ober’s test to use in the clinical setting, both as a diagnostic and therapeutic tool when assessing for IT band contraction and innominate inflare. The IT band contraction and inflare are directly associated with the PHT and a result of adaptation to cross-slope; they may be a common etiology and should be investigated further. Daily treatment is necessary or the patient will fall back out of alignment.