Proximal hamstring tendinopathy is a common occurrence within running, dancing, sports and yoga. With the marathon season just around the corner, I have written this blog post to provide you with a comprehensive overview of hamstring tendinopathy. I discuss why stretching is not the ideal treatment method and what you should do instead.
Please note, this information is not intended to replace the examination of a clinician. If you experience these issues I would recommend that you see a skilled clinician.
Anatomy and Function of the Hamstrings
The hamstrings are a collection of three muscles. The tree muscles form a common tendon at the insertion point of the ischial tuberosity; often referred to as the seating bones. The hamstring stretch down and attach to your lower leg bones; the tibia and fibula.
The main function of your hamstring is to bend your knee and extend the hip. It is therefore important in activities such as running, walking and squatting.
A tendinopathy is characterised by structural changes to the tendon due to repetitive overload. The tendon consists mostly of water and a complex structure of collagen fibres. As a response to overload, the collagen fibres change in nature and more water is absorbed. You may see or feel a thickening of the tendon itself.
A tendinopathy is thought to go through a continuum as it develops. The initial stage is a reactive stage, in which there is a non-inflammatory response to tensile overload. If treated in it’s reactive phase, there is a good change of reversibility as there are no detrimental changes to the tendon itself.
If not treated at this stage and activity not stopped, the pathology will progress towards a state of tendon dysrepair and finally into a degenerative stage. In the tendon dysrepair stage it is more difficult to reverse the pathology due to the more advanced changes in the collagen matrix. However, treatment with good results is still possible. In the most advanced stage, the degenerative tendon, reversibility is unlikely but treatment aimed at addressing pain and function is still possible. In clinic I see this stage of tendinopathy most frequently in the older population and the middle aged athlete.
Hamstring Tendinopathy Symptoms
You will feel a hamstring tendinoptahy in your buttocks, where you seating bones are. Compression of this area, through sitting and stretching, will aggravate the symptoms. It may feel stiff in the morning and it feels like you need to stretch and move first thing. Activity often makes it feel better, especially when properly warmed up. However, after exercise it will often worsen.
Frequent and aggressive stretching of this area can cause lite micro traumas to the area, therefore we need to shift away from stretching and instead focus on strengthening. I commonly see dancers and yogis who continue to overstretch the area and therefore delay healing. I did this myself, and it took me near 6 months to recover because I didn’t stop the causative activity which for me was over stretching into the splits.
Initially we want to offload the tendon. Identify the activity which is flaring up the hamstring e.g. running, aggressive stretching, jumping etc. Then stop the activity to allow the area to settle down. Low grade discomfort for up to 24 hours post activity is OK. But you should stop anything more intense or beyond 24 hours. Additionally you want to reduce activities that will compress the hamstring tendon like sitting and stretching.
When the area has settled and become less irritable, we can introduce progressive loading through strengthening exercises. The exercises are from Goom et al’s (2016) paper (referenced at the end).
The evidence out there suggests that isometric loading is a good starting point. Isometric training is when you contract a muscle for a considerable amount of time e.g. a plank exercise. There is good evidence to suggest that isometric training helps to reduce pain and allows the tendon to be loaded in a gentle way. Below you can see some examples of isometric exercises. Start with holding the exercises for around 30 seconds for three repetitions and gradually build up towards 45 seconds for 5 sets. You can complete isometric exercises multiple times per day (2-3).
When symptoms and irritability have settled considerably, we want to progress the exercises. There is a great deal of research into eccentric strengthening, and for a long time this was the treatment of choice. More recently the evidence has taken a turn and it does not seem to favour one type of strengthening over another. It is therefore a good idea to combine concentric and eccentric exercises to load the tendon optimally. Some exercise options can be seen below.
Finally for stage 3 of treatment, we really want to make exercises more dynamic and functional. Here we can start to incorporate exercises which places some compression on the tendon such as lunges. Some general ideas can be seen below, but you should work with your physiotherapist or strength and conditioning coach to make this more sports specific. The exercises can be made harder by adding weights.
Beyond the Hamstring
It is essential to have an overall look at the function of core and hip stabilisers as well. For example, weak glutes will make you load more into your hamstrings. You can read more about weak glutes here. Postural issues can also be of importance, e.g. an anteriorly tilted pelvis will put increased load on hamstrings in functional activities. By addressing the root cause of the injury, we can prevent the problem from reoccurring. A skilled Physiotherapist or similar will be able to complete a full assessment to establish underlying weaknesses.
- Cook, J. & Purdam, C.R. (2009) Is tendon pathology a continuum? A pathology model to explain the clinical presentation of load-induced tendinopathy, Br Jr Sports Med, vol 43, pp. 409-416
- Goom, T. S., Malliaras, P., Reiman, M. P., & Purdam, C. R. (2016). Proximal hamstring tendinopathy: clinical aspects of assessment and management. journal of orthopaedic & sports physical therapy, 46(6), 483-493.
- Tom Goom, The Running Physio, has a range of information available on his website.https://www.running-physio.com