Last updated: 07-Dec-16
By Karina Teahan
Usually when we think of hamstring injuries we imagine a footballer or sprinter suddenly pulling up from full speed and clutching the back of their thigh. This is the most common type of sporting injury. However, a lesser well known -though more common- injury amongst ultra runners is the proximal hamstring tendinopathy (PHT), and this is what I will discuss in this article.
The hamstrings are located at the back of the upper thigh consisting of three muscles:
the biceps femoris (long head & short head), semimembranosus and semitendinosus.
Read more in the footnote about how these muscles work1. When running the hamstrings become highly active in the terminal swing phase as they work eccentrically to decelerate the swinging tibia and control extension of the knee. They then remain active in the stance phase as they work concentrically as an extensor of the hip joint along with the gluts to propel us forward.
What causes a PHT?
Tendons don’t like sudden change. Here are some examples in which the proximal hamstring can be loaded excessively around the ischial tuberosity. When load exceeds capacity, the result is injury. The tendons thickness, fibrous nature and poor blood supply adds to its difficulty healing itself.
Usually it is not just one factor but a combination of issues that result in PHT.
- Training errors: sudden increase in load especially on hills (this combines compression with tension on the hamstring tendon as the hip flexes more as we run uphill) and speed work.
- Lack of recovery days between training sessions, not allowing the tendons to adapt to new training loads.
- Biomechanical issues:
- An excessively tilted pelvis may be due to shortened hip flexors, resulting in the hamstrings having to work harder from a lengthened/disadvantaged position to extend the hip.
- Glut max weakness/inadequate firing resulting in hamstring overload.
- Poor core/pelvic stability. Often glut med & min weakness will place more demand on the hamstrings. Another lower limb injury may precede a PHT.
- Running style: over striding
- Other exercises: excessive “Good Mornings”, yoga poses such as Downward Dog, hamstring stretches with the hip at 90 degree flexion and knee extended.
- Excessive sitting especially on a hard seat/surface, lots of driving.
- Forward lean posture – often people tend to bend from the hip when doing daily activities like gardening/cleaning/tying shoelaces or at work rather than bending at the knees & ankles also. when repeated long term you may overload your hamstrings.
- Muscle tightness – check muscle length at the knee and ankle
- Lots of stair climbing (similar to hills).
How do I know if I have PHT?
PHT is often described as a deep ache in the lower half of the buttock that can be sharp at times. Your hamstring may feel shortened as you try to run, it may loosen out a little but will feel much worse when you stop and again the following morning, or when you load it. If you do not have tenderness on direct palpation over the ischial tuberosity (best checked in side ly due to gluts bulk) you are unlikely to have PHT. Many other muscles & nerves in this area can produce similar symptoms including referral from the lower back so you may need your physiotherapist to help with a more accurate diagnosis.
How to treat PHT?
Managing a tendon injury doesn’t mean completely stopping and resting, but it does mean modifying certain training habits and day to day activities. It is essential to minimise the compressive and tensile loads over each 24 hour period to allow tendon recovery. This means avoiding or reducing the aggravating factors mentioned earlier.
Suggestions to alleviate PTH include:
- Avoid prolonged sitting especially on a hard chair. Consider a standing desk. This would be beneficial for a myriad of reasons. An egg shell overlay cushion on your work chair or foam wedge for your car seat will all help for the time you do have to sit.
- Avoid forward bend with your knees straight, instead squat down to clean/garden/tie your shoelaces. Address mobility issues around your knees & ankles or quads strength if you have difficulty doing this. Shave & brush your teeth in an upright position.
- Exercises: avoid stretching your hamstrings at this point (even if it goes against all your previous beliefs about hamstring injuries!) as well as: Good Mornings, Downward Dog poses, lunges, leg presses and deep squats.
- Keep a training diary so you can identify the trigger that got you injured in the first place.
- Use a foam roller/trigger point ball, the STICK, dry needling or massage to work out the tight points in the muscle part of your hamstring or gluts.
- Do not compress the hamstring tendon further through direct pressure on it. Correct anterior pelvic tilt – stretch out your hip flexors & quads.
- Tendinopathy2 is not believed to involve an inflammatory process however some research suggests that certain anti-inflammatories play a positive role in managing the reactive (early) phase . They can help by minimising the swelling at a cellular level, which is causing the tendon to be more vulnerable to compression and more sensitive to load. Ibuprofen is one of those mentioned and other generic anti-inflammatories may not work. Discuss with your GP your individual use of anti-inflammatories, due to their side effects.
- Cross training is beneficial but be mindful of what you do. Rowing & cycling in the early stages may irritate the injury.
- Strength & conditioning is important but avoid the aggravating exercises already mentioned (again in the early stages).
- Swimming is a good option and you should start with using a pull buoy then gradually move to a normal kick, as long as there is no latent pain. Personally I find that aqua jogging can irritate this injury due to the increased hip flexion and water resistance.
When should I start running again after PHT?
- You need to be comfortable walking and at rest before you start back running. Research suggests you can start again with discomfort at a level of 3-5/10 on a pain scale, as long as symptoms settle quickly afterwards, and you have no increased stiffness, no sleep disturbance and no pain the following morning. Start with a small jog on the flat. Avoid fast pace and hills initially.
- Running style: avoid over striding, instead shorten your stride, increase your cadence and soften the impact. If it is painful, rest and practice a good walking technique.
There are 3 stages in the continuum of a tendon injury:
Each stage needs to be managed according to the healing progress in each stage.
What are the best rehab exercises for PHT?
The following are some exercises that you can do in the early, middle and later stages of rehab. A good rule of thumb is to know when to progress. This is normally when you have no or very little latent pain the next day and when the affected leg feels as strong as your unaffected leg, when doing an exercise. If it feels different and you have to put in a lot more effort to accomplish the exercise or movement, then you are not ready to progress, and if you do, you risk set back or another injury.
Early on: (daily)
- Start with isometrics3: in standing push the sole of your foot back against the wall and use active hip extension (this recruits the upper part of your hamstrings better). Start 5 x 10 seconds 3 times/day, build to 10 x 10 seconds then work on longer holds of 30-60 seconds 4-6 reps
- Static gluts: 10 x 10 seconds
- Shoulder bridge with heels close to bum (to recruit gluts more than hamstrings) x 10 reps slow controlled
- Concentric hamstring curls in prone, low load no weight initially then gradually add weights single leg
- Leg lifts in prone – keep lumbar spine in neutral, do not allow it to arch, 10 reps. No weight initially then add 1-2 Kg
- Increase weight in hamstring curls
- Shoulder bridge progression – legs further away, staged and single leg
- Shoulder bridge on Swiss ball
- Supine Plank weight bearing on forearms
- Single leg squats with control
- Add more weight to hamstring curls in prone and increase speed and reps of lighter weights
- Hamstring curls on gym ball
- Supine plank with leg lift – this is quite difficult especially to lift the unaffected leg and it will highlight quickly a residual strength deficit
- Other advanced exercises to progress onto as able individually though with caution depending on your capacity and capability include: lunges, step ups Nordic curls, deadlifts, plyometrics (bounding, jumping, landing).
Allow time between strength sessions in the advanced stages, no more than 3 per week, you can do lighter isometrics on in the in-between days.
Lastly be patient with hamstring injuries
Most importantly be patient, this injury takes a long time to rehab and your tendon may be sensitive to changes in load for a long time afterwards. Most rehab programmes are for a minimum of 3-6 months. You may get little set backs along the way and if you do then drop back to the previous stage of rehab until you are back on track again.
Karina Teahan (BSc, MMT, MISCP)
All images Karina Teahan.
About the author
Karina Teahan (BSc, MMT, MISCP) is a chartered Physiotherapist and elite runner who graduated from University College Dublin in 2002. She did a Masters at the University of Western Australia and worked in Dublin, Manchester and New Zealand. Karina is now based in a Primary Care Centre in Cork, Ireland.
1 These muscles have their origin on the Ischial Tuberosity (seat bone) except the short head of biceps femoris which comes off the shaft of the femur. The biceps femoris attaches onto the fibula (outer side of the knee) and the other two attach to the medial knee and its surrounding fascia. In simple terms the hamstrings flex (bend) the knee and extend the hip but work functionally in a more complex manner as they cross over two joints (hip and knee).
2 Tendinopathy is a chronic tendon injury. (Source https://en.wikipedia.org/wiki/Tendinopathy)
3 A type of strength training in which the joint angle and muscle length do not change during contraction (compared to concentric or eccentric contractions, called dynamic/isotonic movements). Isometrics are done in static positions, rather than being dynamic through a range of motion. Plank is one of the most popular isometric exercise, as it challenges all core muscles. Source: https://en.wikipedia.org/wiki/Isometric_exercise