Hamstring Tendinopathy…. a right pain in the arse?
What is it?
Proximal Hamstring Tendinopathy (PHT) is a common injury reported amongst distance runners as well as hurdlers and sprinters. Its usually unilateral but can be found bilaterally. Those that participate in sports requiring changes of direction such as football and hockey can also be susceptible.
It is usually characterised as a deep localised pain near the sitting bone in your bottom (ischial tuberosity). The symptoms are usually irritated during or after running, squatting or sitting. Runners will frequently report pain in the first mile which may then ease off further into the run. Pain and stiffness is often then reported later that day or the following morning. Discomfort will usually be noticeable when running at faster speeds and when running uphill.
The tendons of the hamstring muscles insert on the bony prominence in your bum and this junction is usually the area of injury in PHT. As such, it is regarded as an insertional tendinopathy. Compression of the tendon at its insertion when the hip is flexed forward has been proposed as a key contributing factor leading to injury.
Like most tendinopathies, if not managed well, symptoms can be particularly stubborn and this one literally can be a right pain in the arse.
“All testing for a proximal hamstring Tendinopathy can be conducted in a virtual capacity”
PhysioHub 2021.
What do the hamstrings do?
The hamstring group play a really important role in running and are active at various stages of the gait cycle. Whilst running, they produce hip extension (taking your hips behind you), knee flexion (bending the knee) and they are also needed to control the late phase of the swing phase (when your leg swings in front of you). As they are so busy, and are used to work across two joints, it is not surprising they are prone to injury.
What causes a proximal hamstring tendinopathy to develop?
Several factors are thought to contribute to the onset of proximal hamstring tendinopathy that include:
· Training errors –
o Sudden increase in running volume
o Increase in hill running
o Increase in running intensity/speed such as intervals/track sessions.
· Intrinsic factors
o Range of motion discrepancies
o Weakness/imbalance of lower limb muscles
o Flexibility issues
o Poor movement control
o Postural problems
· Potential Gait factors?
o Overstriding
o Excessive forward leaning
o Increased anterior pelvic tilt
· Other factors that are thought to predispose people to tendinopathies
o Age
o BMI
o Hormonal changes
o Medication (recent use of certain types of anti-biotics).
o Women approaching or during the menopause.
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Diagnosis
A physiotherapist will diagnose a PHT through the following:
· Thorough subjective history
· Palpation or guided self palpation
· Movement tests
· Resisted tests
· Special tests – Bent knee stretch test, Puranen-Orava test.
· Various loading tests.
· Ultrasound scans and MRI scans are rarely required but can confirm diagnosis and severity of condition.
(All these can be conducted in a virtual capacity via an online physiotherapy assessment. See our services page for more info)
Can I still run with my hamstring tendinopathy?
Usually, if pain does not exceed 4/10 during or after running, or if symptoms aren’t progressively worsening with running, then it is ok to continue. Hills and speedwork/intervals should be avoided initially. Also, it is usually advised to not run on consecutive days and mileage/intensity is reduced whilst symptoms settle. If symptoms persist for more than 24 hours after activity, then it is advised to rest for a period of time.
Management of a proximal hamstring tendinopathy.
As with other tendinopathies, the key to managing PHT is progressive loading, performed within a pain-monitoring framework, to restore function and reduce pain. Rehabilitation should aim to improve the load capacity of the hamstring tendons.
Goom et al 2016 suggest that you are progressed through 4 stages of rehabilitation which is expected to take 3-6 months. Progression through these stages is based on symptoms and response as opposed to specific timeframes.
· Stage 1: Isometric Hamstring loading
· Stage 2: Isotonic hamstring loading with minimal hip flexion
· Stage 3: Isotonic exercises with positions with increased hip flexion
· Stage 4: Energy Storage Loading.
As well as appropriate load management, addressing other discrepancies noted in the physio assessment will form part of the management plan. Your physio may provide you with:
· Further strengthening exercises
· Range of motion/mobility exercises
· Control and kinetic chain exercises
· Balance exercises
· Gait advice including drills and cues.
With early intervention and a progressive management plan, a full recovery can often be expected with a PHT. Anectodotally, it is reported that runners frequently make a return to full mileage and performance.
Other Considerations
· Anti-inflammatory medication may be of benefit to settle tendon pain.
· Repetitive stretching of the hamstring is not advised.
· Other forms of exercise such as swimming, cycling can be incorporated to maintain cardiovascular fitness.
For a thorough assessment of your problematic hamstring with an online physio and for a comprehensive individualised management plan, contact the physiohub team.
Physiohub is an online physiotherapy company. We offer a 100% virtual service providing remote physiotherapy assessments, online physiotherapy treatment, online rehabilitation sessions and online DSE assessments. To learn more about the services we provide, see our services page.