For runners, proximal hamstring tendinopathy can be a right pain in the bum… literally. And if it’s not treated appropriately it can stick around for an awful long time.
Ever struggled with a deep ache underneath your buttock, typically made worse by sitting down for extended periods of time? If so, one of the possible reasons is you were suffering from an aggravated hamstring tendon, at the top (proximal) end that attaches to the pelvis. Proximal hamstring tendinopathy can drive runners crazy and hang around for months, all too often because the wrong rehab advice has been given out or read online.
A Quick Look at Anatomy
The hamstring group is made up of three muscles: the semitendinosus, semimembranosus and biceps femoris. As can be seen in the diagram below, although the insertion points of these three muscles are different (the tendons of the semi’s both travel to the inside of the inner knee to attach to the lower leg whereas the biceps femoris travels to the outside), the origin of all three muscles is on the bottom loops of the pelvis (ischial tuberosity), sometimes referred to as the ‘sitting bones’ as they lie deep under the buttock muscle (gluteus maximus).
For runners, pain in the buttock aggravated by sitting down can often be a sign that one of the hamstring tendons attaching to the pelvis has been aggravated, either by a sudden increase in demand (acute injury) or by gradual long term overload (chronic injury). Being at the top end, the injury is referred to as ‘Proximal Hamstring Tendinopathy ‘(PHT), in contrast to injury at the lower attachment points which is called ‘Distal Hamstring Tendinopathy’ (DHT).
What Causes It?
As mentioned above, PHT can be due to either a sudden increase in demand on the hamstrings, e.g. running up a hill without a proper warm up or a gradual overload over time due to inappropriate training or running form. The brain does its job of protecting you from danger by making the tendon stiffer and extra sensitive to load. This is what causes the deep ache in the lower buttock and the occasional sharp pang of pain. Lifting the knee (whether it be putting a sock on or trying to run) can increase symptoms.
Running up hill can particularly aggravate the situation because by having to bring the knee higher the tendon becomes even more compressed against the pelvis. It also increases the load the hamstring has to work through as it drives the leg back underneath you.
As with any tendinopathy, the number one initial goal is to reduce load in order to not aggravate the tendon further. Depending on the severity of the injury, running may need to be stopped altogether then reintroduced gradually in suitable intervals and intensities. Hills and sprints are both likely to aggravate symptoms. You will also probably need to try and avoid sitting on hard surfaces, to reduce the compression issue we mentioned above.
STRETCHING CAN DELAY RECOVERY!
Unfortunately, many runners (and some therapists!) still believe that stretching is a solution for pain, but PHT (and many tendinopathies in the early stages) is a perfect example of where stretching is NOT what you need. Exactly the opposite, in fact – stretching can delay recovery. By assuming a typical hamstring position (trying to touching you toes or stick your leg up on a wall) you compress the tendon against the bone and potentially aggravate it even more! Many runners make this mistake in the belief that their pain is due to ‘tightness’ and that therefore ‘stretching’ is the solution. Very often, we use the word ‘tight’ to describe anything that hurts, regardless of whether range of movement is actually inhibited. What we may mean to say may is ‘sore’, ‘weak’, ‘irritated’ or ‘sensitive’.
Likewise, as many runners discover the hard way, total rest is not always a solution either. Rest, ice, compression, elevation can all be used to manage pain especially in the early stages, but for recovery a graduated loading program will be needed. As always, remember that pain (under 5/10) is not necessarily a sign that you are doing more damage. In fact, the loading exercises you undertake should be heavy enough to provoke a little pain – a good sign that you are loading the muscle sufficiently to stimulate adaption and recovery. Never try and work through a pain of over a 5/10 (where 10 is the worst pain you have ever experienced) as this could over threaten your system and make it get more protective and sensitized.
Exercise choice will depend on the load you can manage, which in turn depends on the extent of the injury. Initially, it may be that you need to stay with static ‘isometric’ exercises, e.g. standing with an exercise band around your ankles and the raising the heel of the painful leg up behind you slightly in order to contract the hamstring. The same thing can be done with you lying on your front with the other end of the band attached to a wall behind you. The important thing is to choose an exercise in which the front of the hip is straight as bending at the hip may cause compression and aggravation of the tendon. Reverse planks and static bridges (lying on your back and lifting your backside up off the floor) can be other popular exercise choices.
Finding a suitably challenging exercise and then gradually progressing it over time is key to successful rehab. For example, once you can do a few 30 seconds of static bridge, you can try 10 seconds of single leg bridge (on the symptomatic leg). Once you can hold the single leg bridge for 30 seconds three times in a row (with a small rest in between), you can go back to two legs but this time with movement. Work your way up to 15 reps and then progress to a few reps on a single leg, etc. Higher up the rehab ladder you can start adding weight.
In essence, the demand of the exercise, i.e. the load it puts through the hamstring, needs to be enough to stop you from being able to complete more than 15 repetitions. This is how you get the hamstring strong enough again for running, as opposed to doing 100’s of repetitions with just bodyweight or enduring 5 minute planks.
A visit to a sports therapist or similar health professional is recommended as they will be able to give you a suitably progressed rehab ladder to follow, as well as check your technique and keep an eye if healing and recovery are moving in the right direction. Regular performance of this circuit of suitably graded rehab exercises is vital. If your therapist does not advise suitable loading exercises from day one, consider visiting another.
Rehab Becomes Prehab
After pain has stopped and a return to running has been successful, your strength exercises need to be continued and integrated into your weekly training program. Research shows that prior injury to the hamstrings is a significant factor in risk of re-injury, especially if you are over 35 years old. In other words, your rehab needs to become ‘prehab’. Though the quadriceps (thigh) muscles will always be able to handle more load than the hamstrings, it is suggested that if relative hamstring strength is less than 60% of the quadriceps, risk of injury is heightened.
Returning To Running
Though we often see running as far less demanding than resistance exercise, the motion of hopping from one foot to the other transmits a suprisingly high amount of load through tendons. Much of the propulsion we use in running comes from what is known as the Stretch-Shortening-Cycle (SSC) in which the tendon absorbs the landing force of running and then uses it like a spring to provide propulsion. If you consider that every mile we run involves each leg hopping forwards some 800 times, this is a tall order if the muscle or tendon is not up to the task. It may not even hurt too much during the run but the irritation caused will soon show itself afterwards. It is vital to ensure that sufficient strength has been restored to the hamstring before introducing running as part of the rehab.
Note that the introduction of running needs to be performed as the strengthening exercises were – with gradual progression. Tendons typically respond 24-48 hours after exercise so it is important to not only start with short, easy paced, flat test runs but also give up to 48 hours to see how well the tendon has coped. For reasons we have already discussed, avoid hill running and speed work initially as these will put too much stress through the hamstrings. Slowly but surely you will be able to increase frequency, intensity and duration and reach full recovery, but do remember to keep up with the strength exercises!