A little over 4 weeks from now I'm due to be running Brighton Marathon. Sadly though I can't run at all at the moment due to a frustrating case of proximal hamstring tendinopathy. I'm hoping though that people can learn from my misfortune and this article might help people in a similar situation.
About 3 weeks ago my marathon training was going brilliantly. I reached that stage where it all clicked nicely into place. Initial aches and pains had completely settled. Running was a real pleasure and I had that feeling I could do anything. I had a nice week of reduced mileage – 4 x 8 mile runs at a comfortable pace – so decided I'd do them all on the hills of the South Downs. I loved it! Every run up there was a pleasure and I found myself wanting to run faster. The temptation overcame me and I did a 1.5 mile speed interval up a long challenging hill. It felt fantastic and even a whole week of hill running hadn't resulted in any niggles.
A couple of days later I did a gentle 8 miler carrying all my work stuff in my backpack and noticed a little niggle in the back of my leg as I went round. It was nothing unusual, niggles are commonplace in marathon training, but it ached a bit the next day. I thought nothing of it and headed out for my 10 miler with 8 miles at sub 7minutes per mile (tempo pace). Although the leg twinged a bit I had no trouble completing the run but when I stopped the pain kicked in and I could hardly walk. Little did I know it but I'd just finished a sequence of training that was almost tailor made for a hamstring tendinopathy!
The hamstring is made up of 3 muscles which all attach to your ischial tuberosity – the bone in your bottom. The hamstring tendon is vulnerable to compression against the ischial tuberosity when the hip is flexed and also has to deal with high loads during running. This combination of compressive and tensile load can make it vulnerable to developing tendinopathy. So, baring this in mind, what 3 activities are likely to cause high load on the tendon; Running uphill, running carrying a heavy load and doing prolonged speed work.
Guess who did all 3!
In fact, I combined running uphill with speed work! Double whammy!
My problem started because the runner in me had completely overtaken the Physio in me! Now the runner is injured and the Physio has caught up and taken over!
The result is a reactive proximal hamstring tendinopathy (PHT). Broadly speaking tendinopathy can be split into 3 main stages reactive, dysrepair and degeneration. These stages are discussed in our article on staging tendinopathy. In terms of managing a tendon we often think of 2 stages – reactive/early dysrepair and late dysrepair/ degenerative.
A reactive tendinopathy typically involves the tendon responding to a sudden increase in load which I achieved quite spectacularly! The response involves thickening and stiffening of the tendon which helps act as a stress shield to reduce load. Pain is usually part of this response and the tendon becomes very sensitive to load (either through compression or tension on the tendon).
My main symptoms are a deep, tight ache in the lower part of my right buttock and posterior thigh with intermittent sharp pain over the hamstring attachment. Pain is worse in the morning and a little better by later afternoon. Sitting on firm surfaces is uncomfortable and initiating hip flexion is painful e.g. To put on a sock. Jogging or trying to run hurts immediately as soon as I push off into my stride. I can run through it but it remains painful and gets more sore if I continue. I'm complaining about it a lot!
I'm very tender over hamstring attachment at the ischial tuberosity. Initially this didn't seem sore but it's best palpated in side lying rather than prone and worth considering that the glutes bulk can get in the way! When it was palpated properly I cried like a little girl!
There are several tests used in assessing PHT – Fredericson et al. (2005) used palpation of ischial tuberosity, the bent knee stretch test, slump and supine plank test. Cacchio et al. (2012) use 3 – the Puranen-Ovara test, the bent knee stretch and the modified bent knee stretch test. Please follow the links for details of the tests, I'll shortly be uploading videos of them.
My diagnosis of PHT was reached based on
- Exquisite tenderness of hamstring attachment at ischial tuberosity
- Pain over hamstring attachment and posterior thigh
- Positive supine plank test
- Presenting history
- Negative tests for lumbar spine, SIJ, sciatic nerve etc.
Commonly the diagnosis is made based on location of pain, tenderness on palpation of ischial tuberosity and changes on MRI. In my case neither the bent knee stretch test or Puranen-Ovara tests were positive which does raise the possibility that there could be differential diagnosis such as pain from the ischiogluteal bursa. I also find my hip adductors are sore and my pain can refer into the groin – an adductor tendinopathy is a possibility but considering everything PHT is most likely.
I think the main cause for my PHT is training error and over enthusiasm! I've never had hamstring problems in the past despite a lot of hill running and speed work. The difference this time is the combination of hill work, running with a heavy load and speed training. Lack of rest is also an issue – rest allows the tendon time to adapt to load. During hill training in the past I've done mainly long hill runs once per week, allowing plenty of time for recovery. This is quite different from 4 hill runs a week with just 3 rest days spread between.
Whenever running injuries happen though it is worth thinking about biomechanical causes. Why was it just one hamstring that was a problem? Why not the Achilles' tendon – surely that also would have been loaded to a similar degree?
For me, biomechanically, the main contributing factor is likely to be tight hip flexors with lack of hip extension. This means that my hamstring has to work harder to extend the hip from a flexed position which places the tendon under greater tensile load.
Hip flexors can be assessed using a Thomas Test;
The test suggests I have very tight hip flexors (though my pain free left side is tightest) and stiffness into hip extension (possibly due to the hip flexors). Rectus Femorus is also tight which leads to more hip flexion when the knee is bent.
The first line of management from reactive tendinopathy is reducing load on the tendon to aid recovery. In this case this means both compressive and tensile load and certainly reducing activities that include both. You aren't aiming to completely offload but just reduce to a level that doesn't increase symptoms. Some tensile or compressive load is probably fine – after all it's hard to completely avoid some activities. But combining compression with tension or doing ballistic movements that involve the tendon's stretch-contract cycle are not recommended in the early stages.
You'll note one very key thing to avoid in the reactive stage stretching the hamstring. This is often recommended incorrectly and can make PHT worse. Another key factor for runners is running up hill – this combines compression and tension on the hamstring tendon as the hip flexes more when we run up hill.
A difficult decision to make was whether to run or rest. Initially I really thought my pain would settle quickly. I've never had an injury completely stop me running. Just a few days after it started I had friends visiting to run across the downs with me and I thought I might be ok. We were planning 20 miles, walking up the hills and sticking to a slow pace. As soon as I started running it hurt but being foolish and not wanting to miss out on a nice run (and some decent banter from @Bryanwe) I ploughed on regardless. 5 miles in I had to give up and skulk off to catch a bus home.
Alison Grimaldi (an expert it hamstring tendinopathy) talks about running and PHT in her excellent podcast. She suggests you may be able to continue to run if you do so on the flat as this will minimalise compressive load. So I rested a week (yes a whole week!) and tried again, this time on the flat. I managed 2 miles but was sore throughout. I tried again a few days later but after 2.5 very uncomfortable miles on the treadmill I realised that I really shouldn't be running yet. Running requires the tendon's stretch-shortening cycle where it behaves almost like a spring and manages tensile load. My hamstring tendon just won't tolerate that at the mo – even a jog across the road hurts. So, as much as I hate it, I have to rest from running. This brings up a useful point to consider with general advice (including advice from this site) – that you have to see how it works for you and your injury not follow the advice regardless. Alison Grimaldi does say you can run with PHT but that doesn't mean everyone should. In my case rest is best!
By cutting out running and avoiding long periods of sitting I'm hoping to reduce both tensile and compressive load to help the tendon recover and come out of this reactive phase. This is arguably the most important treatment strategy at this stage.
Isometric exercises are often recommended for tendinopathy in the reactive stage, they can be helpful with reducing pain and maintaining strength. With PHT the aim is to work the hamstring slowly (I.e. not ballistically) in a position with minimal compression of the hamstring tendon. There will be tensile load on the tendon but only to a level it can cope with. The easiest way I found to do this was in standing holding a chair as shown below. Push your heel up against the underside of the chair while holding the chair down with both hands. In terms of reps and sets the recommendation can vary depending who you ask and I haven't found any specific quality research with clear guidance. I started with 5 reps with a 10 second hold 3 times a day and then built up to 10 reps. You should also aim to do some work with a longer hold and less reps when able, for example 30-60 second hold 4-6 reps. This can be progressed to include very heavy load – if you have a fat friend ask them to sit on the chair!
As well as hamstring isometrics I've also been doing gentle glute squeezes whenever I remember and done a little bridging work. The aim being to try and recruit glute max to provide hip extension rather than hamstrings. I've also been using my sofa stretch to improve my hip extension range and stretch tight hip flexors. I am a fan of taping but I wasn't able to find a technique that offloaded the hamstring effectively. Also the hamstring attachment is a sensitive area and I nearly gave myself an orchidectomy removing the tape!
Later in my rehab I shall be focussing more on glutes and hamstring strengthening and gradually increasing tensile and compressive load on the tendon.
While tendinopathy is not thought to be an inflammatory process anti-inflammatories are thought to be helpful in the reactive stage. Ibuprofen is recommended by Cook and Purdam (2009) and is thought to reduce tendon swelling. This can be especially helpful in PHT. As the hamstring tendon swells it becomes more vulnerable to compression and more sensitive to being loaded, compounding the problem. In theory Ibuprofen should be helpful in preventing further compression and irritation. I say “in theory” because not all researchers agree with the role of anti-inflammatories in treating tendinopathy. Some are concerned that they may have a negative effect on tendon healing (although ibuprofen is not thought to do this).
Always consult your GP or pharmacist before taking medication.
Progress so far…
Initially my pain was a fairly constant ache that was worse in the morning but improved as the day went on. Now it's only present during activities that load or compress the tendon. It remains worse in the morning – the acid test is washing my feet in the shower! As I balance on my affected leg and lift my good foot up to wash it I always get my symptoms. The combination of taking weight and flexing the trunk with the leg straight is clearly putting pressure on the sensitive tendon. This remains a marker for me, if it stops being painful I'll know I'm making progress.
Overall I am improving but it is slower than I'd hoped. Brighton marathon is a month away and I currently can't run across the road without pain. It's doubtful if I'll be able to run and almost certain I won't beat last year's time. This is the price you pay for overdoing your training! I've already had to pull out of The Grizzly, which was hugely disappointing. On the positive side though I have learned a lot from this. It has changed my priorities from trying to squeeze everything in to seeing the bigger picture. In the attempt to not miss a run here and there I have injured myself and ended up missing 3 weeks including over 120 miles in my training schedule.
Research and Further reading
I haven't found a great deal of research on PHT. The best resource has been Alison Grimaldi's brilliant podcast that I've linked to above. James Dunne has written an excellent piece about PHT which details tests and has some really helpful comments from tendon expert @fizziowizzio who has also been really helpful with tendon articles for RunningPhysio (despite me calling him a girl!).
There is the research piece (mentioned above) from Michael Fredericson who is widely publish on running injuries and rehab. Fredericson et al. (2005) follows the rehab of a case study (an Olympic runner) who is recovering from PHT. He recommends stretching but more recent advice would say this is more likely to aggravate than help, especially in the reactive stage. As far as I'm aware there haven't been a great deal of trials comparing different treatment regimes for PHT. As a result many of the pieces, including that of Fredericson, are expert opinion rather than being based on rigorous research.
What next for
Over the next week to 10 days I shall be increasing my rehab, focussing more on working glute max and hamstrings with single leg bridges. I plan to cross train more – I haven't done this so far as the tendon has been quite irritable and easy to aggravate (I had planned to cycle but I suspect the combination of hip flexion and sitting wouldn't help).
If I can single leg bridge and supine plank pain free I might start some light jogging (if comfortable). Unfortunately I'm playing a bit of a waiting game at the mo. I just need to be patient and let the tendon settle. I'll let you know how it goes….