Tight Hamstring Syndrome (THS) – Causes, Risk factors, 6 Important Symptoms and Diagnosis

Reviewed by Dr Ganapathi

Tight Hamstring Syndrome (THS)

Tight hamstring syndrome is caused by a problem in the lower back

This condition most commonly affects the children and teenagers.

How does Tight Hamstring Syndrome happen?

This condition most often happens when a spinal bone (vertebra) in the lower back slips forward. Spinal bones normally rest on top of each other.

Hamstrings are the main flexors of knee joint and tight hamstrings cause altered biomechanics, resulting in joint reaction forces during routine daily activities.

Knee remains in semi-flexed position leading to gravitational falls on the anterior of the knee.

The length-tension relationship of quadriceps may also disturb which further aggravate the pathology with extra tension on patellar tendon.

This may result in patella-femoral dysfunction and pain syndrome.

Tight hamstrings not only disturb the biomechanics at knee joint but also joint reaction forces and mechanics of hip and ankle joints.

This results in abnormal gait patterns and abnormal foot loading.

Planter fascia undergoes repetitive trauma that can result in planter fasciitis and heel pain

Hamstring muscles are located at the back of the thigh and attach to the pelvic bone.

If a child has THS, these muscles can become so tight that the child may have trouble walking.

If one vertebra slips forward and out of place (spondylolisthesis), it can put pressure on the nerves that supply the muscles of the spine, hip, and upper legs.

What are the causes?

Here are the most common causes of the Tight Hamstring Syndrome

The slipped vertebra that leads to Tight Hamstring Syndrome may be caused by:

• A birth defect (congenital).
• Damage from activities that involve arching the back.
• Damage from a tumor or infection of the lower spine.

Research Facts about Tight Hamstring Syndrome

Study 1 : A retrospective study conducted in 102 children showed the below underlying diseases in these 102 children suffering from Tight Hamstring Syndrome

1. Slipped lumbar disc
2. Spondylolisthesis or spondyloptosis
3. Fractures
4. Langerhans’ cell histiocytosis
5. Spondylodiscitis
6. Osteomyelitis, facet joint
7. Osteoid osteoma
8. Spinal ependymoma
9. Epidural lipoma
10. Ewing’s sarcoma
11. Leukemia focus
12. Arachnoidal cyst
13. Meningitis
14. Spinal stenosis
15. Aneurysmal bone cyst
16. General fibrous bone dysplasia
17. Myositis
18. General angiomatosis
19. Dysplasia of the vertebral arch
20. Sacral meningocele
21. Chordoma

Study 2 : Another retrospective study conducted on 102 children. These children presented to the clinics with tight hamstring syndrome in the past 22 years (between 1980 and 2001).

This study includes the largest number of patients with tight hamstring syndrome analysed so far.

Seventy four children (73%) suffered from severe underlying diseases. In more than one-third of all THS cases (38 of 102 cases; 37%), it was observed intra- or extraspinal tumorous alterations. In 15% of the cases (15 of 102), osteomyelitis or spondylodiscitis was diagnosed. Only in 27% of the cases (28 of 102), disc protrusion, one of the commonly known underlying diagnoses (14 cases), or higher-grade spondylolisthesis/spondyloptosis (14 cases) were the inciters.

The results of this study suggest that tight hamstring syndrome in childhood can be an initial symptom of an associated, usually severe disease.

This study concludes that therefore further diagnostic evaluation is required when tight hamstring syndrome is observed.

A rapid initiation of an adequate primary therapy could be indicated.

A cross-sectional study was conducted in 200 students. The objective of this study was to find the correlation between prolonged sitting (minimum 6–8 hours duration) and tightness of hamstrings in students. Sedentary lifestyle has emanated as a new attention for research on exercise and health.

Probability sampling was used on random basis to assess the flexibility of hamstring muscles using the straight leg raising (SLR) and active knee extension test.

A manual goniometer was used for range measurement.

All information was taken on predesigned pro forma.
The mean age of 200 students was 20.3 ± 1.63 years. The mean value of SLR was found to be 60.97 ± 10.21, and mean value of popliteal angle was 47.65 ± 8.06. Most of the students, 164 (82%), had tightness according to SLR test. There was a statistically significant difference between the popliteal angle and chair sitting hours (P = 0.010), and an inverse correlation was found between SLR angle and chair sitting hours (r = −0.56, P = 0.000).
The Conclusion of the study is that tightness of hamstrings is observed in a majority of the students. Long-duration sitting can be a contributory factor in hamstring tightness.

What increases the risk?

The following factors may make a child more likely to develop Tight Hamstring Syndrome:

• Being a boy who is 7–8 years old.
• Having a personal or family history of spondylolisthesis.
• Doing activities that have an increased risk for the spinal injuries that can lead to THS. Examples are gymnastics and football.

What are the symptoms of the syndrome of spondylolisthesis and tight hamstrings?

The symptoms of this syndrome of spondylolisthesis and tight hamstrings are

• Severe restriction of straight leg raising
• Inability to bend the trunk forward
• A peculiar gait

The mechanism that produces the hamstring spasm is not well understood, but certainly hamstring tightness may accompany any irritative lesion of the cauda equina.

A study presented detailed reports of two cases of spondylolisthesis and tight hamstrings, which was treated surgically, and the authors have knowledge of seven similar cases supplied by five of their colleagues.

Are overweight and obese children are at increased risk of Tight Hamstring Syndrome?

A study was conducted among 122 third year primary schoolchildren. The objective of the study was to assess and identify if there is a significant relationship between obesity, overweight and the presence of Tight Hamstring Syndrome.

55% were boys and 45% were girls among the 122 children.

Out of these 122 children, 49.1% were within normal BMI, they weren’t overweight, 25.4% were overweight and 25.4% were obese.

The Tight Hamstring Syndrome test results were normal in 42% of these children.

34% of them have Tight Hamstring Syndrome degree I and 24% had Tight Hamstring Syndrome degree II.

Does Neurodynamic sliders promote flexibility in tight hamstring syndrome?

A study was conducted with the objective to explore the intervention effect of home-based neurodynamic slider program on hamstring flexibility.

Fifty men who are physically active were included in the study

These men were assigned to either performing a neurodynamic sliding technique (3 × 20 reps) or a static stretching protocol (3 × 30″) on a daily basis for a 6-week period.

Hamstring flexibility was assessed by means of the Straight Leg Raise at baseline, immediately after the intervention and after 4 weeks follow up.

There was no between group baseline difference in hamstring flexibility.

The repeated measure ANOVA showed a significant interaction effect for group × time (p < 0.001). Independent sample t-test showed a significantly higher increase in flexibility gain in the neurodynamic group immediately after the intervention (p < 0.001), as well as at 4 weeks retention analysis (p = 0.001) compared to the static stretch group.

In conclusion, neurodynamic sliders might be more efficient than regular static stretching in affecting hamstring flexibility in the long run. Neurodynamics play an important role.

What are the symptoms of Tight Hamstring Syndrome?

The most common sign of THS is the Hamstring tightness that prevents a child from flexing his or her hip with the knee extended.

This movement involves moving the leg forward at the hip with a straight knee. The affected child may also complain of low-back pain.

1. Hamstring tightness
2. Pain, tingling, or numbness in the thighs or buttocks.
3. A stiff, waddling walk.
4. Low back pain, Back stiffness or spasms.
5. Pain when pressing on the lower back.
6. A sideways curve of the spine (scoliosis).

In children, the symptom complex of tight hamstring syndrome is very rare and most commonly has a variable pathogenesis.

What induces these clinical symptom complex is

1. a fixed contraction of the lumbar, ischiocrural and gluteal musculature which
2. fixes the lumbar vertebral column and the hip joints typically in an extended position when the full extended leg is lifted up 

THS results from numerous underlying conditions such as intra and extraspinal diseases.

How is Tight Hamstring Syndrome diagnosed?

Tight Hamstring Syndrome may be diagnosed based on your child’s symptoms and a physical examination. The health care provider may do the physical examination

• Feel your child’s spine for a specific type of deformity (step-off) in the lower lumbar area of the back. Pushing on this area may cause discomfort.
• Check whether lifting your child’s legs at the heels (when the child is lying down) causes the child’s back to lift off the exam table.

Imaging tests may also be done, including:

• Plain X-rays. These may show a vertebral slip when your child is standing.
• CT scan.
• MRI.
• Bone scan.

How is this treated?

Treatment for Tight Hamstring Syndrome depends on the cause of the condition and how severe it is.

• Mild cases of THS may be treated with a period of rest followed by exercise to stretch the hamstrings and strengthen the back and abdominal muscles.
• If THS is due to a tumor or infection, your child may need to be admitted to a hospital for treatment.
• If THS is due to a slipped vertebra from trauma, wear and tear, or a birth defect, treatment may include:
  • Resting at home until pain goes away.
  • Taking NSAIDs (nonsteroidal anti-inflammatory drugs) to relieve pain and swelling.
  • Wearing a back brace. Your child may need to wear a brace for 3–6 months.
  • Physical therapy. This will begin once pain is relieved. The goal is to make the abdominal and spinal muscles stronger and to stretch the hamstring muscles.
  • Follow-up X-rays and imaging studies. These will be done after several months of treatment to monitor your child’s condition. They will show whether the vertebra is healing well or slipping farther out of place.
  • Surgery if:
    • The vertebra has slipped farther.
    • THS symptoms do not get better after 6 months of rest and wearing a brace.

Stop Smoking

• Smoking can slow down healing or lead to an infection.
• Stop smoking for as long as possible after surgery.
• Ask staff for resources about quitting smoking or nicotine replacement therapy.
• If you smoke, you should try to avoid smoking until your jaw has healed.

Follow these instructions at home:

If your child has a back brace:

• Have your child wear the brace as told by your child’s health care provider. Remove it only as told by the health care provider.
• Loosen the brace if your child’s toes tingle, become numb, or turn cold and blue.
• Keep the brace clean.
• If the brace is not waterproof:
  • Do not let it get wet.
  • Cover it with a watertight covering when your child takes a bath or a shower.

Activity

• Work closely with your child’s physical therapist to learn the exercises your child should do at home.
• Make sure your child avoids activities that cause pain during recovery.
• Have your child avoid activities that involve arching the back.
• Do not let your child participate in contact sports. Make sure you know which types of recreational activities are safe for your child.
• Ask your child’s health care provider when your child can return to normal activities.

General instructions

• Give over-the-counter and prescription medicines only as told by your child’s health care provider.
• Keep all follow-up visits as told by your child’s health care provider. This is important.

Contact a health care provider if:

• Your child’s symptoms are not improving.
• Your child’s symptoms are getting worse.
• Your child develops new symptoms.

Get help right away if:

• Your child loses movement or feeling in the back, legs, or hips.
• Your child loses control of bowel or bladder functions.

What research says about Tight hamstring syndrome?

1) A Case Report of 17 year old male proved that the early diagnosis of THS and its cause can prevent additional surgeries.

Details of this case report – This 17 year old patient complained of low back pain and pain in the right leg. The pain radiated to the back right leg for the last two months.

He used to walk with limited forward flexion and right knee flexion.

Straight leg raising test (SLRT) showed elevation of whole body like a board with painful. He complained of pain when his legs was elevated to 30 degree.

Popliteal angle of effected side was 87 degrees.

There was no weakness of lower extremity.

MRI of lumbar spine showed L5-S1 right far lateral disc herniation.

It was diagnosed THS and the underlying disease was lumbar discopathy.

Medical treatment, conventional physical therapy (15 session) and Mulligan traction straight leg raise technique (TSLR) were done (9 session).

2) Another case report of a 19 year old male who complained of left leg pain which spread to the back left leg last four month.

SLRT was leading to elevation of whole body like a board with painful and patient was suffering from pain when his legs was elevated to 40 degree.

He was standing and walking with limited forward flexion and increased flexion at left knee. it was also decided that patient’s diagnosis was THS depending on lumbar discopathy.

Medical treatment, conventional physical therapy (15 session) and Mulligan TSLR technique were applied (9 session).

After the therapy, his toe touching distance was 25 cm and SLRT was negative. Low back range of motion (ROM) was full.

Does the Spondylolisthesis and Tight Hamstrings occur together?

The syndrome of spondylolisthesis and tight hamstrings occurs in adolescent children

Here are some ways to address or manage tight hamstrings:

1. Stretching Exercises: Regular stretching can help increase flexibility in the hamstrings. Perform gentle hamstring stretches daily, holding each stretch for at least 30 seconds.
2. Yoga or Pilates: Practices that focus on flexibility, such as yoga or Pilates, can be beneficial for stretching and lengthening tight muscles, including the hamstrings.
3. Foam Rolling: Using a foam roller or massage tools can help release tension in the muscles and improve flexibility. Roll the hamstrings gently to reduce tightness.
4. Strength Training: Strengthening the muscles around the hamstrings, such as the quadriceps and glutes, can help balance muscle strength and reduce strain on the hamstrings.
5. Proper Warm-up: Before engaging in physical activity or exercise, ensure you properly warm up to prepare the muscles for movement and reduce the risk of injury.
6. Avoid Prolonged Sitting: Long periods of sitting can contribute to tight hamstrings. Take breaks and stretch regularly if you have a sedentary job or lifestyle.
7. Hydration and Nutrition: Staying hydrated and consuming a balanced diet can support muscle health and flexibility.

Sources

Tight hamstring syndrome and extra- or intraspinal diseases in childhood