How to Treat Proximal Hamstring Tendinopathy
A Guide to Running with Proximal Hamstring Tendinopathy
What is Proximal Hamstring Tendinopathy
Proximal hamstring tendinopathy (PHT) is a common overuse injury involving degeneration of the tendon’s mechanical properties, often resulting in high hamstring/buttock pain with loading and/or compression activities such as running, squatting, and sitting.
Proximal hamstring tendinopathy is common among distance runners, sprinters, and athletes in track, football, and hockey.
What Are Some Proximal Hamstring Tendinopathy Symptoms?
Individuals with proximal hamstring tendinopathy typically experience deep, localized pain at the ischial tuberosity (sit bone) that gets aggravated during or after activities such as running, lunging, squatting, and sitting (especially on harder surfaces).
ISCHIAL TUBEROSITY - “Sitting Bones”
Hamstring Insertion Point
Hamstring tendinopathy pain usually decreases after a few minutes of warming, but is worse after the activity. For example, PHT pain is felt at the beginning of a run, improves during the run, and worsens after the run.
Activities such as slow walking on a level surface, standing, and lying, are usually not painful.
Individuals with proximal hamstring tendinopathy may experience stiffness in the morning or when starting to move after prolonged periods of inactivity (getting up from sitting).
What Causes Proximal Hamstring Tendinopathy?
Proximal hamstring tendinopathy is caused by excessive load to the hamstring tendon over time. This is typically seen when a runner introduces hill repeats / speedwork into their programming too soon. Research clearly demonstrates that the hamstrings are a major muscle group responsible for faster running.
Proximal hamstring tendinopathy occurs gradually. Initially, the runner only feels pain in the area after their run. As the condition progresses, the runner experiences symptoms in the tendon during the run. Traditionally, the runner will say that symptoms start earlier into the run as the injury is gradually progressing. It also begins to require a longer period of time into the run for the tendon to warm up and for pain to decrease.
What is the Typical Proximal Hamstring Tendinopathy Recovery Time?
Tendon pain takes a long time to heal. Proximal hamstring tendinopathy rehab typically takes at least 3 months. It can take up to 6 months for this condition to resolve, provided proper treatment interventions are utilized. A sit and wait / rest approach does not work for treating tendinopathy-related injuries. Tendinopathy-related injuries require progressive overload. One must monitor the response to the stimulus / dosage of load (as will be discussed below).
What Does Proximal Hamstring Tendinopathy Rehab Look Like?
Rehab for proximal hamstring tendinopathy will depend on how irritable the symptoms are.
In general, proximal hamstring tendinopathy rehab should include temporary training load modifications when symptoms are more irritable. Specifically, we want to decrease the amount of high compression and energy storage activities such as sprinting, hurdles, and uphill running until symptoms are more stable and less irritable.
Simultaneously, we should work on progressively loading the hamstring tendon to reduce pain and restore function. Pain is okay and actually encouraged to adequately rebuild the loading capacity of the hamstring tendon, provided we follow the pain monitoring model.
Pain Monitoring Model is as follows:
Pain is allowed to reach 5/10 during activity
Pain immediately after activity is allowed to reach 5/10
Pain the next morning after activity should not exceed a 5/10
By following this pain monitoring model, we can determine if the current load is tolerated well and whether you should continue/progress your loading activities. If pain levels exceed 5/10 during activity, immediately after activity, or the next morning, the amount of load is beyond the tendon’s current capacity and the activity should be regressed to a previous level.
Any deficits in strength/endurance (hamstring, glutes, core), flexibility (hip flexor, quadricep), or movement control (squatting, lunging, step downs, etc.) should be addressed.
Lastly, proximal hamstring tendinopathy rehab should include energy storage and release (jumping, hopping, cutting) to normalize load capacity in the entire lower extremity.
When treating our runners with proximal hamstring tendinopathy, we also perform a biomechanical running analysis to correct any habits that may be contributing to the condition. For example, runners with PHT tend to demonstrate overstriding or excessive forward trunk lean during their running analysis.
Should I Use a Seat Cushion for Proximal Hamstring Tendinopathy?
Using a seat cushion can reduce the compression of the hamstring tendon in sitting by shifting the pressure from the sit bones to the back of the thigh. Our patients with proximal hamstring tendinopathy typically find it more comfortable to sit with a seat cushion or a rolled up towel.
Rolled up towel under the thigh
Our therapists also advise avoiding prolonged sitting. If your work requires you to be sitting, take frequent breaks to stand, move around, and come back to sitting. If you have the option to use a standing desk, we advise that you stand for part (or all) of your work day.
Common Hamstring Tendinopathy Exercises We Prescribe
Our therapists start with the least with the least aggressive exercise interventions, and will progressively increase the stimulus, as tolerated. Below is an example of each type of muscle contraction. This is typically the order the exercises are introduced during the rehab process, but the progressions or regressions of these exercises are utilized, depending on the tolerance of the runner.
Isometrics: Hamstring Set
3-5 sets of 30-45 seconds
Eccentrics: Physio Ball Rollout
3 sets of 12-15 repetitions
Concentrics: Hamstring Bridge
3 sets of 10 repetitions
Plyometrics: Tantrums (Knee Flexion Variation & Hip Extension Variation)
Hamstring Extension Tantrum
Hamstring Flexion Tantrum
3 sets of 20-30 seconds for each (remember that the hamstring is both a knee flexor and a hip extensor, so training it as both is important when training to return to sport)
Proximal Hamstring Tendinopathy Exercises to Avoid
There are no specific exercises you need to avoid if you have proximal hamstring tendinopathy. Our therapists do recommend that you avoid exercises that excessively aggravate the hamstring tendon during or after the activity. As discussed above, we typically allow for pain at a 4-5/10 during and after the exercise. Symptoms should return back to baseline fairly quickly. If they do not, then that is an exercise you will need to modify (intensity, reps, sets, range of motion, etc). If the activity is not tolerated at all, then we recommend you temporarily avoid that movement until it can be re-exposed to the system safely.
There are some exercises that do commonly aggravate the hamstring tendon when it is acutely irritable, and those typically include deep squats, Romanian deadlifts, Nordic hamstring curls and glute-hamstring raises. With that said, these are all exercises that eventually need to be reintroduced into the runners strength training routine when they are improving and able to tolerate more hamstring loading.
Can I Run with Proximal Tendinopathy?
Our therapists provide clearance for running as long as the runner’s pain / symptoms don’t exceed a 4-5/10 that night or the next morning. We want to see that the runner’s symptoms are back down to baseline within 24 hours before we decide to make any progressions to the program. This is why we initially don’t recommend back to back days of running (we want to monitor symptoms over a 24-hour period).
Some common modifications we make to the runner’s program initially are:
No speedwork (stick to easy runs)
No uphill running (stick to flat surfaces)
We also recommend that the runner perform a proper warm up that includes hip openers, hip swings, lateral lunging, etc. It is also advisable to walk for 5-10 minutes before you begin to jog for a few minutes. Then you can begin your run. That provides the hamstring tendon with enough time to warm up and tolerate faster paces.
As the runner is improving in their rehab, we begin to increase running frequency first (back to back days), followed by running intensity (strides, then shorter intervals, then longer intervals, then hill repeats - typically in that order).
Closing Remarks
We hope you found this article helpful. As always, consult with an expert in this field so they can advise and guide you. If you would like to work with us to resolve your hamstring pain, contact us below to speak with a physical therapist.
Disclaimer: This is not intended to be formal medical advice. Your individual needs should be met by the appropriate health care practitioners. Please consult with a trusted provider.
Dr. Paul Nasri PT, DPT, OCS, COMT
Dr. Vincent Liu PT, DPT
Doctor of Physical Therapy
The Game Plan Physical Therapy