Proximal hamstring tendinopathy – a case study…me

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.

History…

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).

Symptoms…

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!

Examination findings

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

  1. Exquisite tenderness of hamstring attachment at ischial tuberosity
  2. Pain over hamstring attachment and posterior thigh
  3. Positive supine plank test
  4. Presenting history
  5. 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.

Contributing factors…

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.

Treatment

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.

For further reading on tendinopathy in general I highly recommend Cook and Purdam (2009) and (2012) as well as Magnusson, Langberg and Kjaer (2010).

What next for RunningPhysio LimpingPhysio?

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….

 

 

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71 Responses to Proximal hamstring tendinopathy – a case study…me

  1. sportinjurymatt March 14, 2013 at 8:47 pm #

    With so many interesting blogs out there in Internetland, it’s normally too time consuming to read every word… a certain amount of speed reading is normal. HOWEVER, this is a fine example of a post where every word adds to the experience. It’s rare to find a great physio who finds time to not only train for a marathon but also write about it. So much info here will be of huge use to runners. I know the frustration of a running injury ruining a race plan so I truly hope you get some great karma back for sharing the experience. Great work Tom!

    • PhysioTom March 14, 2013 at 8:56 pm #

      Wow, thanks Matt for your great comments as ever! Much appreciated!

      • David October 31, 2014 at 7:35 pm #

        Hello,
        We should not Stretch hamstrings it only aggravate the injury as you stated above, when i do the kneeling hip flexor Stretch I can also feel a Stretch on my hamstring. Should i stop this hip flexor Stretch?
        Thanks

    • Julia January 27, 2016 at 5:04 am #

      I am a young athlete and i just got diagnosed with this!
      I have a major competition coming up and i an stressing about whether if i should compete or not!
      Not sure what to do.
      Please help!!!

  2. runshoe March 14, 2013 at 9:38 pm #

    Good article. Will the follow up detail sportinjurymatts proposal.

    • sportinjurymatt March 14, 2013 at 10:20 pm #

      Proposal as in helping Tom’s recovery? I’d like to see some daily exercises to help increase R.o.M in hip flexors (incl Rec Fem), with the aim of taking tension off the hamstrings, especially if Tom’s pelvis tends to habitually be anteriorly rotated. Or are you suggesting I ask his hand in marriage?

  3. runshoe March 14, 2013 at 10:31 pm #

    Why not release his psoas AND marry him?

  4. Chris Johnson March 15, 2013 at 11:27 pm #

    Witty and well written article. I hope you are on the mend.

    Thought you may find my criteria helpful when it comes to determining when you are ready to run (provides a simple framework and is what I use when working with injured runners and triathletes). We in the medical community need to agree on specific guidelines to determine when one is ready to run because the standard of care is too far and wide!

  5. Thesocialphysio March 16, 2013 at 2:34 am #

    If you are desperate to keep your cardio improvements and keep running why not trial some deep water running with waist flotation belt? Less compression force ?may feel ok.

  6. Marina March 18, 2013 at 5:20 pm #

    Matt – I have the same problem. I went to get ART treatment done and now it seems that my knee is also hurting. Have you experienced that? What do you think about ART treatments and message treatments to stretch the hamstring muscle for this injury?
    thanks for taking the time to read.
    Marina

  7. Ian Brown May 11, 2013 at 9:37 am #

    Hi Tom, thanks for your efforts on this tender subject! I have just self-diagnosed myself with reactive tendinopathy of my right proximal hamstring.

    I have been on a squatting and deadlifting frenzy for past month. I have had a little niggly ache at ischial tuberosity for a few days and then yesterday i finished my first set of deep heavy squats and sat down to recover as is normal for me….and couldn’t as the pain at IT was intense!

    Walking, stairs and sitting are painful and palpation of IT at hamstring origin is quite exquisite!! I’m thinking all those squats with lots of hip flexion have set it off…for past 6 weeks I have also been ignoring a little bit of anterior hip joint pain on flexion and abduction on same side; coincidence?

    As a physio mate of mine says “healer, heal thy self”!

    Great resource Tom, I regularly point runners to your work.

    You know me better on twitter as SportsTherapy56

    Regards

    Ian B

  8. Anthony May 23, 2013 at 11:46 am #

    Great read. Really helpful. There isn’t much good information on PHT. I’ve also been suffering from a proximal hamstring tendinopathy for the last 4 months. Has been to sore to even contemplate running. A little too much to soon over the last triathlon season in Australia. Have been given a lot of different advice, but Grimaldi’s podcast has pushed me in the right direction.
    Stopped stretching and started with isometric prone hamstring flexion. After a week it stopped aching in sitting. However, over the last couple weeks i’ve had little improvement, although it hasn’t got any worse. Once i felt it settled I added 4 sets of 6-8 reps of bilateral heavy hamstring curls (35kg) which I perform daily in an effort to increase strength. I have ceased all other rehab exercise. As i know Jill Cook recommends strength training, although she doesn’t really specify how much weight to use, so I have been going as heavy as i can control with good form (without pain). Thoughts on this progression?
    I’m a little confused as to whether I should be simply trying to unload the tendon until I can run again (complete rest except for prone hamstring isometric exercises) or should I continue with strength training?

    Although my recovery is still very slow.

    Ouch. I hope you can make it back in time for the marathon.

    • PhysioTom June 5, 2013 at 3:55 pm #

      Hi Anthony,
      Sorry for slow reply, I did write something for you a few weeks back but it didn’t post correctly and got lost in the ether somewhere!
      Your hamstring curls sound good, are they in prone or seated? Prone is better as in sitting the hip is flexed and there will be more compression of the hamstring tendon.
      In terms of reps, sets and load the jury is really out on that! I have been discussing it at some length with fellow physios recently. My thought is that you want to build strength first in a non-compressive manner. Prone hamstring curls are ideal for this. I would be doing them as a single leg activity with a heavy load – I’d start with 10 rep max (the maximum weight you can lift 10 times with good control and no pain). 3 sets of 10 reps with each set separated by 1-2 minutes. I would do this 3 times a week with a rest day between each session.
      In terms of returning to running ideally you should develop equal strength and power first but I’ve tried a gradual return to flat running and have had no problems. If you do this it should ideally be pain free both during and after. Some research suggests you run with up to 5 out of 10 pain but symptoms should settle quickly after with no extra stiffness or pain the following morning.
      I hope that’s useful and gives you some ideas for your rehab – as ever it’s always best to see a Physio rather than rely on online advice especially as I am unable to examine you or anything! There will be more on the site on PHT coming soon…
      Best of luck
      Tom

    • Dea Elisabeth Lenz Nørregaard October 27, 2015 at 9:34 am #

      How do you make prone isometric exercises for hamstrings? What do you use as resistance? The standing one with a chair is to hard for my hamstrings right now…and the one leg standing aggravates it…
      Thanks for a great article….

  9. Alice July 2, 2013 at 8:47 pm #

    Dear Mr. Running Physio–

    Thanks so much for writing this! I can only assume I did myself exactly this injury about 4-5 weeks ago now. I went to the GP who said they had no idea what it was and just to replace the Ibuprofen I was already trying with Naproxen… which was a bit frustrating.
    What you describe fits exactly with what I’ve been experiencing and the distribution of pain/aggravating activities is spot on. I also first noticed it after I’d run up a hill! It’s a hill I run up frequently and always at the same pace with no trouble, so I don’t really know why it happened so suddenly. I’ve been trying to run/limp through the pain with some success (I did stop running for two weeks, but when that didn’t help I got frustrated with the inactivity), but I tried running this evening and it was just impossible.

    I am really hoping you might be able to tell me how long this problem lasted for you in the end? I literally can’t wait for my leg to get better! I’m in the middle of revising for some big exams and I feel so restless that it’s hard to concentrate. Also, I’ve been continuing to cycle to work as provided I stay seated, this doesn’t hurt. Does this seem reasonable or might I be accidentally prolonging the injury even though it’s causing me no pain?

    Thank-you so much for any reply and I hope you managed to get over it and back to your normal self! 🙂

    Alice

  10. Anna July 4, 2013 at 9:02 am #

    Hi Anthony,

    How is your rehab going? I have the same issue with exactly the same symptoms. I wanted to ask whether your hammy feels/felt weak as well, almost heavy when compared to the healthy hammy? I have been advised to rest for two weeks and I am not feeling any better after 12 days. I have been avoiding sitting and being very careful but one odd movement and I feel like I am back to square one with the dull consistent pain. Would like to know how you are progressing? Thanks

  11. Anthony July 4, 2013 at 11:08 pm #

    Hi Anna, my recovery is still pretty slow, i haven’t run in 5 months for more than 10 minutes. Although I have been swimming a lot. Cycling is a very bad choice of cross training for PHT Alice and will prolong the injury as it both compresses the hamstring tendon and then puts the hip into flexion.

    I have read and listened to everything on PHT and really don’t think rest is the best idea for an extended period of time as the hammy will just get weaker, which seems to be half the problem. As Tom mentions you should at least be doing some static exercises even in the initial reactive stage. I had one of my friends test my strength in lying against resistance and my sore hammy is extremely weak compared to my un-injured side, so wish I had got into the strength work earlier.
    To address the strength issue (which I now am pretty sure is the primary issue with tendinopathy – correct me if i’m wrong), I have been trying a new rehab program for approximately 3 weeks which involves gradual progression against resistance of hamstring curls in prone, along with functional and static exercises which seems to be going well. Although I still dread sitting for more than 5 minutes and have got myself a cushion to sit on in the car!
    I feel like I have forgotten how to do natural things like sitting down and walking. If you have any new insights let me know!

    • PhysioTom July 5, 2013 at 9:25 pm #

      Hi Anthony,
      Sorry to hear you’re struggling with this. I know exactly how you feel! Have to seen my more recent posts on strengthening for PHT?
      Prone hams curls are a good option but be patient – strength changes take time, most studies on tendinopathy worked for 12 weeks to improve strength.
      Keep us posted on how you’re getting on.
      Tom

  12. Anna July 5, 2013 at 9:17 pm #

    Thanks Anthony!!! Do you still have a dull ache at rest, if not, roughly how long did it take to subside? I developed my PHT after alot of straight leg dead lift work, stairs and sprints. Do you swim with a pull buoy? When did you start swimming?

    Sitting and driving really aggrevate it, are there any other “dont do’s” that you have picked up on over time?

    I have had 10 days of complete rest and started isometrics two days ago, but I still get the intermittent dull ache when I do certain things. I also walk with an extended stride on my injured side to avoid pain. Can you walk normally?

    Sorry for all the questions, this injury is an absolute pain! I would have rather broken my leg!

    Thanks. Anna 🙂

    • PhysioTom July 5, 2013 at 9:28 pm #

      Hi Anna,
      Patience is key I’m afraid! I know it’s frustrating! Stick with what you’re doing for a little longer and it will settle. It took mine around 2-3 months to settle, but stopping running did help.
      Where are you based? I might be able to recommend a really good Physio for you to help
      Tom

  13. Anthony July 6, 2013 at 12:34 am #

    Hi Anna, the walking pain subsided after about a month, even though i was doing everything wrong for it e.g. stretching, cycling, a lot of walking. Then i did another triathlon which made it feel red hot for another 2 weeks or so.
    At the moment i can walk with no pain, I think it should settle in 2 weeks of looking after it really well. I might have a little sharp pain if i bend down to pick something up really suddenly. Otherwise it just hurts in sitting. Even the rehab exercises are 99% pain free, although they certainly work my hamy hard. If i have to drive for a long time the pain lingers for a while. I initially started swimming with a pool buoy, however once out of that really initial painful stage i found it was no different with or without the pull buoy and I now even use a kick board/flippers regularly and swim >10km a week. If i were you I’d start swimming once you can walk around comfortably pain free, and if it causes any more pain that lingers after don’t do it.

    A couple little things that may help
    – do daily rehab exercises religiously
    – find a physio who has experience with middle distance/long distance runners to check out you’re sit to stand/posture/running style/gait
    – shorten your stride length to at least a normal/shorter stride with a soft impact. I find walking in bare feet helps.
    – Have really good posture: no forward lean… as the hammy acts across the hip joint e.g. when you’re brushing your teeth
    – All Tom’s articles for PHT trump everything else on the net. Thanks Tom!

  14. Anna July 6, 2013 at 1:38 am #

    Ok great! Will stick with the exercises and give the swimming a go. I am jusy really struggling with not being able to do any cardio! Even arm weights and tightening my core etc tend to engage my glutes and tweak the hammy. So irritating. I am based in North Sydney. Any recommendations would be greatly appreciated. 🙂

  15. Michael Allen July 6, 2013 at 1:43 pm #

    Initially (Sept 12) I did not know what the problem was; tight hamstring and pain to my groin around the adductor muscle. Things settled down and I started Yoga. Unfortunately and despite a variety of stretches, periods of rest and swimming I decided (March 13) to use a power plate. Do not use a power plate ever!!. I aggravated my sacroilac joint and boy is that painful!! I have seen a Consultant in Sports and he believes I have tendinopathy of the Hamstring. He has suggested an injection into the hamstring muscle at the top whilst undergoing a an ultrasound. What are the risks with such a procedure? Is this the only way to have steroids into the injury.?

    • PhysioTom July 6, 2013 at 1:58 pm #

      Hi Michael, I’m not an expert on injections I’m afraid so have a discussion of risks and benefits with your consultant.
      My view would be that there is a slight increase risk of tendon rupture after steroid injection but this risk is fairly small. From what I’ve read the evidence to support steroid injections for tendinopathy isn’t great. If it were me I’d fully explore normal rehab options first including isometrics ex’s then progressive strengthening of the hamstring (in positions without hamstring tendon compression). If that failed then I might consider an injection.
      Have you tried to rehab it?
      Thanks
      Tom

  16. Adam July 16, 2013 at 8:19 am #

    Hi. I have been putting up with my injury for the last four months now. Symptoms sound spot on, other than my constant, dull pain occurring half way down the my leg, slightly to the right.
    I stumbled across this handy resource when I suspected my injury to be more than just a strain. I’m fairly sure mine came about due to hill running and dumbell squats. I’m a keen runner and cyclist. I often cycle 100km a week and have kept this up having read cycling can help in the rehab of a hammy injury. So it that totally wrong? Shall I start swimming and continue with resistance band exercises? It sure is going to kill me not being able to run and cycle in the height of summer here in the UK.

    Thank you for sharing your expertise and hope your recovery is going well.

    • PhysioTom July 19, 2013 at 8:39 pm #

      Hi Adam,
      Cycling can aggravate but see how it goes. If it doesn’t hurt while you cycle or afterwards it’s probably fine! Just make sure you don’t over do it!
      Tom

  17. Rick August 23, 2013 at 6:33 pm #

    Thanks for the best article I have read so far on this condition. I just had this hit me a couple of weeks ago, after a particularly intense session of speed work two days after a nice, long hill run. I had to cancel plans for a half and a marathon due to not being able to train for them.

    One thing I haven’t seen anyone mention yet (and maybe that’s because it’s just me) is that I while running isn’t a real option right now, I can walk/hike all day without much in the way of pain, as long as I have taken a few days off from running first. It’s only when I run at speed that I stretch out the leg and aggravate the injury. So at least I have that as an alternate means of getting some cardio while working the rehab exercises as well. I tried the bike this morning, though I couldn’t see how sitting would help, and it didn’t. It’s more sore today than it was yesterday. So, walking it is.

    There seems to be a real disagreement over whether hamstring stretching as part of the rehab is a positive or negative. My strings were pretty tight (I’m 55, and until last year was pretty sedentary for the past 10), and so I’m thinking that some mild stretching to increase overall flexibility is probably ok, using relative pain levels to define for me what “mild” is. I’ll switch from Aspirin to Ibuprofen, too (only been trying the Aspirin for a day or two), to see if that helps the recovery time.

  18. Alice August 24, 2013 at 9:04 am #

    Hi, I posted earlier. My problem with my left hamstring lasted for about 2.5 months in the end, but it’s more or less completely gone now. In the end I think the best thing I did was to just stop exercising completely. To the person above who found it wasn’t aggravated by walking: nice idea to keep going, but mine definitely was!

    Anyway I’m so pleased and relieved that it’s gone even though I’ve put on some weight and totally ditched my fitness (tragic yet predictable consequence, I suppose), and I’m back to running again. The only thing I’m no longer doing is that I now find myself very apprehensive of running up hills. The VERY last thing I want is to do myself the injury twice, these have been the longest 2.5 months ever. I would like to get back to running care-free but I want to minimise the chances of doing whatever I did last time to stress it.

    Does anybody have any strengthening exercises or things I ought to do to minimise re-injury? I’m conscious that I probably have a terrible core so I’m already trying to work on that.

    • Anna August 24, 2013 at 12:44 pm #

      Hi Alice, it is so good to hear that you have recovered! I was wondering whether you could detail what rehab you did exactly, exercises, amount of rest, any massage etc? I am still seeing very little improvement and am struggling to do any form of exercise without aggrevating it! I have done a lot of reading and they say one of the best strength exercises for hammy health are weighted hamstring curls (Jill Cook mentions this in her podcast). Thanks in advance! 🙂

      • Alice August 25, 2013 at 4:38 pm #

        Afraid I’m probably not much help – literally all I did was leave it alone! I had some big exams so I just sat around all day with my books and stopped cycling, running – I even took the tube everywhere instead of walking. All of my attempts to cure it through exercise etc. just seemed to prolong it and keep irritating it so even small things were painful… but as with all these sorts of thing, it’s impossible to know whether the rest made it better or if it would always have improved by itself. In the end I just decided as exercise seemed to aggravate it, I’d just stop exercising. And it worked, although the extent to which it made THE difference – who knows!

        The only thing I did do which worked for me in terms of monitoring when it felt good enough to get back to exercise again was to do this:
        http://masterexercise.com/wp-content/uploads/2011/04/bridge-Exercise.jpg
        And see if I could do it pain-free with both legs and then try doing it with the injured leg by itself. I didn’t start exercising again until it was pain-free with the injured leg.

        Dunno if that helps at all, but good luck!

        • Anna August 25, 2013 at 9:34 pm #

          Thanks so much for your reply Alice. Ok so two and a half months of nothing at all? No isometrics etc? Kind of depressing bc I can actually do the single leg bridges pain free but still have a very dull consistent ache at that insertion point. Very frustrating! Thanks again 🙂

  19. Emma August 30, 2013 at 9:52 am #

    Totally confused….

    I have had issues with my legs for going on 8 years or so now and after seeing many physiotherapists, all of whom diagnosed me with something different, I finally found one who fixed me. I have one leg shorter than the other (which i know is very common) this caused achilles tendonitis and a collapsed left arch. This was eventually fixed with 2 months rest, regular massage and orthotics for my trainers lifting my left leg slightly and my fallen arch. For a year and a half, I had zero issues and actually thought it was a revelation! After having ran for years through the pain, i couldn’t believe the improvement in my speed and fitness.

    About 4 months ago, I started to get some niggles, so went back to my podiatrist who told me i needed new orthotics as my current ones were a little battered and over used. Since have them remade, I have experienced increased pain in my hamstrings, my left big toe and my left knee. I have been back several times but he informs me that the orthotics are correct. I am at the frustrating stage where i am in so much pain in my hamstrings, I can hardly walk. I can’t put any pressure on my knee, and haven’t been able to run or cycle for 3 weeks now. I have like a deep throbbing ache in the tops of my hamstrings/glutes and, unlike others, it isn’t too bad in the morning but gets worse throughout the day. I try and stretch a LOT but this seems to make it worse. I also do a lot of yoga but again, I just don’t know if this is making it worse?

    I have been to see my GP who has referred to me to a leg and knee specialist next week with the hope to get an MRI scan.

    After reading Alice’s post, i’m kind of thinking that 100% rest is the way to tackle this initially, and only return gradually to exercise once the pain completely leaves.

    Would anyone recommend continuing with Yoga and stretching or will this, in effect, make it worse? I have also started cycling in the last 2 months and not sure if this has aggravated it or even caused it?

    I feel so down about this, more so that my physio hasn’t even suggested I may have PHT, but after reading these comments/blog, i feel like this is something I definitely have…

  20. Anthony September 2, 2013 at 2:18 am #

    If it is PHT there is no argument about stretching. There is no role for it at all during the reactive phase of tendinopathy and once the initial pain has settled with isometrics and rest.

    I think people would be better off thinking that it is purely a strength deficit, probably caused by any number of factors. initial treatment should be aimed at very slowly strengthening the hamstring tendon as opposed to improving flexibility. Yoga will make it much worse (particularly avoid downward dog).

  21. Anna September 2, 2013 at 3:36 am #

    I agree entirely with Anthony. I have been to numerous physios, had an MRI and consulted with a surgeon who operates on avulsed and torn hamstring tendons. There is no evidence of even a partial tear on my MRI. The injured hamstring tendon (unless caused by a traumatic event) is likely the result of a number of factors including over use, lack of stretching, glutes not firing, pelvic tilt etc. Unless you treat the underlying cause of the problem it is likely to be re-occuring.

    I have found the process of getting out of consistent pain the most trialing. I stopped all exercise and have been concentrating on glute work and isometrics. As primarily a runner I have pathetically small and inactive glutes so my hamstrings and quads step in to take the load. I was very sceptical at first about the whole theory of “glutes not firing” but I am starting to feel some definite improvement with my PHT since starting on the glute work in particular. I have been swimming with a pull buoy for cardio. Doing gentle lower back exercises and manual hip flexor work twice a day. I avoid sitting and stand, kneel or lie down where possible. I have also had the belly of my hamstring taped to alleviate the pressure of the muscle pulling at the tendon attachment point. After a lot of ineffective and painful taping at first, I finally found a taping method that makes it feel better.

    In the very early stages of my wonderful journey with PHT I attempted a pilates class and it almost killed me. I think one of the important things to remember as Tom says above,is that the tendon has a delayed response to load, so whatever you do today you won’t know the response until the following day. That is what I have found anyway.

    I also read a research article recently on the surgical treatment of hamstring tendinopathy. After an average 24 months of failed conservative treatment for this condition the subjects had a hamstring tenotomy done. The interesting part was that when they had the operation the surgeon confirmed that they did not have any full or partial tears despite the subjects reporting of considerable pain at the insertion point. Our understanding of tendon and tendon pathology still seems to be very much in its infancy!

    Good luck with your rehab, go slow and I would strongly recommend avoiding the stretching!

    🙂

  22. Rick September 9, 2013 at 3:07 pm #

    Thought I would give an update on my condition, in hopes that it might help or encourage another. With the help of people like you, I was able to diagnose myself with at least a minor HHT condition.

    I began treating it thus:
    * No running for 3 weeks. Very short attempts at Cycling and Elliptical were painful as well, but walking/hiking was not, so I kept that up.
    * Bridges to work the hamstrings and glutes.
    * Started doing squats – not heavy weights (150 lb) but enough to get things working.
    * Ibuprofen the first week to reduce swelling and discomfort
    * MSM/Glucosamine at 3000 mg/day.
    * Stretching of hip flexors, but NO stretching of hamstrings.
    * Changing my stride a bit to land more forefoot rather than rearfoot. You can look up Newton running to see what that does.

    I am happy to say that I was able to run an easy 3 miles last Tuesday, 5 on Thursday, 9 on Saturday and 6 today, all with no pain. I’m a little slow, due to the layoff and getting used to the new stride, but NO hamstring pain. In fact, the only time it’s painful now is when I sit for long periods of time. I am hoping that the continued stretching will help with that.

    So there IS light at the end of the tunnel!

  23. Lachlan September 14, 2013 at 10:35 pm #

    G’day Tom,

    I know you wrote this a long time ago now but for some reason it just popped up on my Twitter feed this morning just as I was sitting down to edit my masters assignment on proximal hamstring tendinopathy! Nice work on the blog. Needless to say I’ve recently been doing a lot of reading on the subject and have also recently done Alison Grimaldi’s online course and her two-day practical workshops on “Dynamic stabilisation of the hip and pelvis” and “Understanding tendinopathies of the hip and pelvis”. Anyone who has the opportunity… I highly recommend these courses.

    Given that you wrote this in May I’m hoping you’re well and truly running again now but I thought I’d offer a couple of additional suggestions on the acute management phase based on what I’ve been learning myself lately. There is also a great new article by Cook and Purdam that you’d probably enjoy: http://www.ncbi.nlm.nih.gov/pubmed/?term=The+challenge+of+managing+tendinopathy+in+competing+athletes

    * Ibuprofen or even the “polypill” combination (http://www.ncbi.nlm.nih.gov/pubmed/18077212) are good options to try to look at settling the cell proliferation happening in the active phase of tendinopathy.

    * Semimembranosus and biceps femoris long-head are the most commonly injured portions of the hamstrings- particularly SM with proximal tendinopathy (http://tinyurl.com/mptd4j8). Both of these are most active at the hip (as opposed to the knee) due to the distribution of their muscle fibres. Therefore you could make your initial static exercise a little more specific by placing the sole of your foot against the wall instead of under a chair and using active hip extension to produce the force.

    * … And hopefully this one is not the case for you, but… Remember that it’s possible to have pathological change in a tendon with no symptoms, so just because this is your first experience of pain you may not only have reactive tendinopathy… If progress was found to be particularly slow imaging might reveal some old damage in there too.

    Again, nice work on the blog. Hope you found my little additions interesting.

    Regards,
    Lachlan

    (@LachlanWakeling)
    http://www.beleura.com.au

    • Anna September 15, 2013 at 11:32 am #

      Hi Lachlan,

      I have had this condition for 6 months now (have not run the entire time), my physio has me doing a few exercises but was wondering what key exercises Alison Grimaldi recommends?

      Also interested in what you have read about the pathology and pain. My MRI showed very minor damage but the pain would suggest otherwise.

      Thanks

      • Lachlan September 19, 2013 at 12:06 pm #

        Hi Anna,

        As per the posts below I might be writing a guest blog on the topic for Tom. The sort of things I would be talking about are not earthshattering revelations, more some fine tuning of rehab for slightly different presentations and a couple of different ways of performing the same sorts of exercises that Tom has already outlined. Essentially he has covered things very well in his other blog outlining a rehabilitation for this condition. Something that Alison focuses on is the issue that Tom has highlighted regarding loading the hamstring in positions that do not involve much or any hip flexion. However, sometimes the Tendinopathy is not right up on the insertion of the hamstring on the pelvis, and in these situations I think the avoidance of hip flexion is nowhere near as important.

        The principles of graduated loading, beginning with isometrics and progressing to slow, heavy load are also very important. Again, as Tom has said, only performing these heavy load exercises 3 times a week at the most – to allow optimal recovery and adaptation of the tendon – is important. I do find that having patients perform light isometric exercises on the days between these “heavy days” can be beneficial.

        Importantly, getting a rehabilitation right for this injury is often very difficult and requires close management from a physiotherapist who really understands the intricacies of this condition and the pathology of tendinopathy in particular. Unfortunately there is no one recipe. No 2 patients are the same and being able to give you individual advice is pretty much impossible.

        Something that I do see is sometimes missed in a patient’s treatment plan is addressing the control of the trunk-on-the-pelvis and the pelvis-on-the-hip. Deficits in hip abduction are common, sometimes hip flexion is deficient. These issues absolutely need to be addressed alongside the hamstring itself.

        Then, of course, there’s diagnosis. If the diagnosis isn’t right the best PHT rehab in the world is not going to fix it.

        If after 6 months you’re not really getting anywhere I think it’s sensible to get another opinion. Your diagnosis and/or rehabilitation plan may need to be reassessed. Of course there is the possibility that the diagnosis is right and you’re doing all right things… Some tendinopathies just don’t settle very easily.

        You could start to consider adjunct therapies. At a basic level I find dry needling to be very beneficial… Although there is no specific research to back this up. Extracorporeal shockwave therapy also has some good literature to show that it can be beneficial for the pain of Tendinopathy (although I haven’t seen it specifically researched for this condition). Getting on top of the pain with something like this can really help move your rehab along much faster. A number of sports physicians in Australia are currently using autologous blood, or platelet rich plasma, injections. This remains a very controversial practice with some people swearing by it and others howling it down- if I had a patient who had done absolutely everything else I would certainly consider trying this. You would need to discuss it in detail with a good sports physician (i.e. specifically trained sports doctor).

        Then there is the question of your pain versus your imaging findings. This is a can of worms. There are 2 main things that come to mind. Number one: some degree of pain referral from the lumbar spine, maybe even the thoracic spine, sensitising the area. Number 2: adaptive changes in your nervous system due to the fact that you’ve had this for so long… This topic in itself is a huge area well beyond the scope of this post!

        Hopefully I haven’t left you with more questions than answers.

        • Anna October 3, 2013 at 5:35 am #

          Thanks Lachlan. Sorry for the late reply! I really appreciate your feedback. I am seeing signs of improvement, but it is painfully slow. I have moved on to eccentric exercises and core stability and glute work and can now sit for longer than 5 min which is a positive! I am speaking with a surgeon who operates on hamstring tendons re: PRP injection.

          Also read an interesting article on tendon repair and collagen synthesis. Will post a link when I find it again.

          Thanks again,

          Anna

    • PhysioTom September 18, 2013 at 4:07 pm #

      Hi Lachlan,
      Thanks for your comments, you clearly know your stuff when it comes to PHT!
      Would you be interested in writing us a guest blog on it?
      I have written more on the topic here; running-physio.com/PHT-rehab
      But I’d love to hear your views on it.
      Many thanks
      Tom

      • Lachlan September 19, 2013 at 11:34 am #

        Hi Tom,

        Thanks for your kind invitation! I think there are a few things I could write about that readers interested in PHT would find interesting… More as an adjunct to what you’ve already written than anything. I hadn’t seen your rehab article until you pointed it out – another great blog, you’ve covered the topic nicely. I can offer a few insights on options for rehab variation for differences in presentation, some thoughts on progressing rehab to the end stage (depending on whether the person is a ‘runner’ or they happen to run in addition to other sports) and one or two other things to try. It would probably slot in nicely between your existing article and the one you are planning to write about a return-to-running program.

        Things are a little hectic at the moment so I wouldn’t be able to get around to writing anything for you to 3 or 4 weeks. What do you think?

        • PhysioTom September 19, 2013 at 11:59 am #

          Hi Lachlan,
          That sounds great. It’d be really good to have your input!
          Timeframe wise 3-4 weeks is totally fine. Just send what you’ve written to runningphysio@gmail.com
          Thanks!
          Tom

  24. Lachlan September 14, 2013 at 10:37 pm #

    PS: Let me know if you want the original articles

  25. Nikali October 5, 2013 at 2:01 pm #

    I have had a nagging feel in my hamstrings for a few months along with pain in the groin area. The pain radiated to my back and I stopped all forms of exercise for two months (very frustrating). However I ran a 5k two weeks and the pain has been tremendous. The past three days have been extremely painful in that sitting, standing, and lying down are all painful. Getting rest has been nearly impossible. Is this normal in the reactive phase? Everything else I have read online fits my symptoms and I have an appointment with a PT next week. I have been taking lots of Motrin with little help along with using BioFreeze on the glute and hamstring. At this point I would do anything to be able to get rest and sleep for more than thirty minutes at a time.

  26. Louise November 1, 2013 at 12:55 pm #

    Great to know I am not the only one struggling with this. Very slow progress and physio has recently suggested shock wave therapy and a few papers say it has got good results. Anyone have any experience/comments on this?

  27. Kenji November 1, 2013 at 11:42 pm #

    Tom do you think you could recommend a good physio for proximal hamstring tendon rehab for the greater Seattle area?

    I’m also curious if Tom or anyone on here has any recommendations for my 6 month-in stage of rehab. Here’s my timeline:

    6 months ago I woke up with a sharp pain right at the ischial tuberosity hamstring connection, a day after doing 5×5 power cleans at the gym and a couple days after doing an intense trail run (with lots of steep incline sprints mixed in). I must have had tight hamstrings for the cleans, but didn’t feel a thing until the next morning. For a month things like light jumping hurt a lot, but I could still walk fine (stopped running completely though). Then I was dumb and tried to squat about 80% of my normal working load at the gym when I thought it was getting better, and after 3 warmup sets a set at 200lb left my leg feeling terrible, so I limped out of the gym with regret.

    For the next 2 months I couldn’t sleep at night for more than an hour at a time, and only a heating pad applied to the hamstring would ease pain as it would relax the muscle some and ease the strain on the tendon. Sitting in the car was immensely painful, as was putting on my shoes in the morning, damn near impossible most of the time actually. That first moment of standing up out of bed was scream in agony worthy for about 40 days (sometimes I would choose to let go of my trained social inhibitions). Worst feeling I can remember since being alive. For a chunk of that first month, I was an idiot and had my girlfriend help do assisted stretches on my hamstring (by holding it 6 inches off the ground; later it would only go 2 inches off the ground), and getting an intense massage that caused me to not be able to walk the next day. I also reintroduced running at one point, ~3 mile runs 2-3 times a week when my doctor friend (the first of 4 doctors I got opinions from) had suggested the idea that it could have been piriformis syndrome. Not long after this point I realized I was making things work and sought out further medical attention.

    3 months and 3 doctors later (6 months total since first symptoms), I have significantly less pain, and have regained 30-40% of my range of motion. However, lately I get sciatica in my ankle, something that didn’t happen early on. One time about a month ago I over did my rehab routine I had been doing for a few weeks (multi-hip machine leg swings at minimum possible weight and super light prone hamstring curls at lowest weight possible, 8 second long negatives, as instructed by the doctor), and felt a sharp prick on the tendon. The next day my girlfriend noticed a purple bruise under the buttock. Amazingly, the sciatica had reduced by 90%.

    However the sciatica is coming back, but it goes down to a minimal level when I take NSAIDs. Isn’t it too far in to still be in an inflammatory stage? Perhaps I’m injuring chronically, or I am building up too much scar tissue near the nerve. Weird thing is that while pain has decreased significantly

    Also I’ve eaten a kilo of low-temp processed bovine colostrum, which hopefully helped speed up healing with its 95 immune factors and 87 growth factors (including ample igf1). Has anyone else thought about trying colostrum during their rehab?

    Thanks for reading such a long comment,
    Michael

    • Anna November 3, 2013 at 10:39 pm #

      HI Michael,

      I have had this issue since March this year. In my experience with the condition, it sounds like you are going a bit hard too early ( like I did!!!!). I am 7 months in (and with an MRI only showing a strained hammy insertion point) and am only just starting to do body weight resisted eccentric hamstring curls. It is a very slow and gradual process unfortunately and to limit the amount of scar tissue generation and further damage I wouldn’t be pushing it too early. I started with eccentric band resisted exercises to begin with, and after years of doing stiff leg deadlifts/squats/hammy curls, it seemed insane that I could barely work with my own body weight. But it is definitely worth not pushing it, any twinge or shooting pain at the insertion point I have always found to be bad news and a sign that I was pushing it way too hard.

      Definitely read through all Tom’s articles on this topic, there is some really good information and if you stick to it, you will definitely see improvement.

      Good luck 🙂

  28. dave November 10, 2013 at 4:14 am #

    hi guys does any1 know if you can ger surgery for high hamstring tendinopathy. I have had this for 2 years now and due to my work (plumber) no matter how much rehab, injections cortisone and prp, shockwave, art i just cant get rid of my pain, its making me go insane. i have tried everything unddr the sun but wont go. please can some1 help me. regards dave

    • Anna November 10, 2013 at 10:46 pm #

      Hi Dave,

      You might find this interesting. Have you had an MRI?

      http://link.springer.com/article/10.1007/s10195-013-0226-2#page-1

      Definitely worth reading the above re: treatment of chronic tendinopathy.

      🙂

      • Dave November 10, 2013 at 11:36 pm #

        Anna u r an absoloute legend thanks so much for that info! Do u no who I could see in Melbourne for this? Thanks again regards dave

        • Anna November 11, 2013 at 4:38 am #

          Hi Dave,

          I know a good surgeon that can give you an opinion in Sydney and can ask if he knows anyone in Melbourne. Send me an email and I will send through the details.
          sh@kulpana.com

          Anna

  29. Cathy November 13, 2013 at 1:17 pm #

    I was pointed to this website by my husband’s physio. He’s being treated for achilles problems (all down to lack of strength in the calf).

    Anyway, I have suffered with hamstring/glute pain since March 2011. It all started during a step class. I kicked my leg forward and…ping…immediate pain at the top of my hamstring. I limped through the rest of the class but was in real pain. Prior to that I had often suffered with pain in that area whilst (and after) running although I had always just ignored it, doing the odd stretch in a rubbish attempt to alleviate it. After the step class incident I sought physio treatment straight away and was diagnosed with a tear to the tendon where it joins the hamstring to the sitting bone. I was given stretches and strength work but it never really did the trick and although the severe pain and discomfort subsided, it has not been right since.

    Pain was always worse when sitting and driving for long periods (that isn’t as bad now), running aggravated it and I would have to stop and stretch out after a few miles. Since then I have not run more than about 6/7 miles.

    This spring I thought enough is enough and went back to physio and went through all the history and symptoms. However, after a couple of months the physio gave up as she wasn’t sure what she was treating or where the source of the problem lay. I was having some obvious sciatic problems (which caused confusion), particularly when driving with the pain going down the side of my leg and into my foot, but doing a nerve stretch didn’t bring on the pain.

    I visited a consultant and he diagnosed high hamstring tendonopathy at the ischial tuberosity. I was sent for an ultrasound guided cortisone injection with the ultrasound showing inflammation, calcium deposits and small tears at that point, right next to the nerve. So the swelling and stuff going on with the tendon was aggravating the nerve, hence the pain in my leg, knee and foot. The cortisone gave me a period of about 6-8 weeks pain free. I continued with the exercises, including nordic stretches, and gradually built up my running. But, the pain is back although slightly different. I’m not getting the deferred pain in the middle of my hamstring and sitting and driving are OK but I now have pain around the hip area when I put weight on my bad leg and even more so when I then bend forward (just as Tom reports in his case study). I also feel it in my hip flexor and groin area.

    I am now going to see the consultant again to see what’s next but reading this suggests it’s all to do with strength so I must get into a rigid routine of the suggested exercises. This injury is driving me insane!! I’ve got a place in the London marathon next year so have a huge incentive to get sorted once and for all, but I am not confident 🙁

  30. adriansears May 23, 2014 at 2:53 pm #

    Have been struggling with this for 4 years. Had a spinal fusion in 2000,completely successful and ran Boston in 2010 , have had a lot of physical therapy, PRO injections and a cortisone shot. STILL RUNNING BETWEEN 40 and 50 now. Injury will not allow speed work of too much hill running. I live in the mountains so hills are hard to avoid.
    Out of ideas…….surgery!!!!!

    Thanks

    Adrian

  31. Sean August 12, 2014 at 6:45 pm #

    Hi Tom,

    My issue deals solely in my left upper hamstring (proximal) on the sit bone. When I feel my glutes back there, there is a definite thickening of some sort compared to the right. I feel it when I paw back with my left foot but not really any pain, just a stiff, dead spot. This injury goes back to 2006 when I woke up one morning and started to limp where walking was very slow, no stairs at all. I thought I tore something in there. Sitting and rising from a chair was an effort. I could not run for 3 months. Had an MRI done in 12/2005 and the report showed hamstring tendinopathy. Fast forward to 2014 I am still running about 35 miles a week. Any distance above 6 miles that upper left hamstring gets weak and cannot support in that area and alters my gait forcing a slower pace. Sometimes I have to pull over and stretch the left hamstring just to get normal range of motion back and release the stiffness. Bottom line, that injury/tear back in 2006 healed in not the right way with scar tissue or something in there that has weakened my left hamstring. I’m finally getting this taken care of with a new doctor and MRI. I will keep you posted.

  32. J. MacMillan August 20, 2014 at 7:40 pm #

    Exactly 1 year ago, I ran my last race. The next day, my butt hurt and running hills was likely the worst thing to do. An ultrasound showed that the hamstring was injured at the insertion point. After several false starts, including wasting a month and a half water running, I’m finally on the mend. Physiotherapy started in May with 3 weeks of shockwave accompanied by eccentric hamstring exercises. I’m now running twice a week, about 8-12 k each time.

  33. Stuart Wadlow September 4, 2014 at 7:44 am #

    I’ve had PHT since December 2012. This is the worst injury a distance runner can get. I am awaiting surgery on the tendon from am orthopaedic consultation after every type of treatment failed to do anything. Bio mechanical compensations caused gluteal bursitis which is being treated with cortisone. I am an athletics coach and personal trainer by trade and my days of 75 minute half marathon seem a distant memory. The injury just crept up on me one weekend and I fear my competition days are over

  34. Hannah September 11, 2014 at 1:44 am #

    These are outstanding exercises for the hamstring! This can be a tough injury. Check out this article; it has a pretty good take on this:

    http://marsblackandgesso.com/post/97128629884/an-18-month-relationship-with-high-hamstring-tendinitis

  35. Zizou January 16, 2015 at 6:55 pm #

    Hi Tom/People,
    Those isometrics in the chair should be performed 2 to 3 times a day, 7 days a week? Without rest?
    Many thanks in advance.

  36. Annette April 11, 2015 at 12:21 pm #

    After reading and relating to Tom’s inspiring blog and all the above comments, I feel encouraged.

    My initial introduction to PHT started late October 2014, this was after completing an intense training week which included a social game of ten pin bowling. I was progressing nicely into a 5×5 weight training program, running 3 – 5 km most days, attending a circuit class twice a week, as well as a yoga class once a week. At 52 years old I had never felt better ; )

    I experienced an excruciating cramp in my right hamstring an hour or so after bowling. By the end of that week was experiencing spasms down the hamstrings and calves of both legs and into the feet. I tried working through it in hope that it would sort the problem out…..this failed and only made the pain worse.

    I started on ibuprofen but ended up in the ER at Al Habib Hospital in Riyadh (Australian expat working in Saudi Arabia) on an IV of morphine followed by a full spinal MRI. The MRI showed a bulging disc with no compression, but nothing else. I had an ultra sound done on both legs, mostly checking for blood clots (as I had a DVT in the past), this was also clear. I visited a Neurologist who after looking at the report and doing a minor examination informed me all I was suffering from was cramps and spasms. That I should up my magnesium, calcium and zinc for a while and eventually they will subside!

    By Christmas I was in a wheelchair and taking Lyrica for pain relief. Before the end of January I had slowly reduced the Lyrica and thankfully found a qualified sports therapist who has treated my condition as PHT. My rehab is slow but am showing steady improvement. It’s now nearly six months since this all began and I am back in the gym doing upper body weights only. I cannot manage to run but am walking better albeit slowly. Because both legs were involved I have not been confident in the water but will soon be attempting some rehab in the pool. If I overdo anything my hamstrings experience a thumping sensation, pain in my calves have all but disappeared.

    I would be lying if I said I didn’t miss my running, especially when I’m home in Tasmania running up the river path.

    Thank you to all the above, your comments have been invaluable. I really related to your story Anna ;(

    Would love to have any feedback on how your rehabilitation is going now.

    Many many thanks.

  37. Lisa Deefholts May 12, 2015 at 4:51 pm #

    Hello Tom,
    I was so relieved to read your post and diagnose myself ( dangerous) with PHT. I injured myself 3 weeks before the London Marathon. Like you, I was on an easy week but was tempted to run really fast at the end as I was feeling good. I’d run up a pretty steep hill also and at the end mg hamstring felt a bit sore. I saw the osteopath a few days later and he said to keep running but take it easy. However, I’m not to good at taking it easy when I run on my own and on the Saturday I ran up a massive hill as part of a 10 mile loop. My leg and left glute felt tight but there was no pain whilst running. The next morning I couldn’t sit on the train in to work without acute pain and I could hardly walk in to work when I got off the train.
    I saw the osteopath again and he said it was ok to do really short slow runs if it didn’t hurt. Problem is, though it didn’t hurt at the time it’s actually got worse. I wasn’t doing it every day. I’ve since stopped everything but it still really hurts if I sit, stand, walk. I’m supposed to be flying to Ibiza on Thursday and am worried that sitting that long on a plane will make it worse. I can take shed loads of pain killers to cope with the discomfort but I don’t want to make it worse. Will it? Or should I cancel the trip? It won’t make me feel any more depressed than I already am.
    Thanks. Lisa

  38. Steve May 27, 2015 at 2:52 pm #

    Hello Tom. Strangely I believe I have this problem, but I am not a runner. I purchased a car 9 or 10 years ago with a really heavy clutch and I have had burning pains in my left buttock and sciatic type pains running down my left leg and sometimes into my left foot after I have been sitting for a while. My hamstrings are also very tight. I have been treated for ischial bursitis, had injections, and my current physio started treating me for periformis syndrome a few weeks ago. When I told him that I had a area where if you pushed it it would really hurt, he is now beginning to think that it is where my hamstrings join on to me and some periformis sciatic combination issue. I have tried hamstring stretches over the past few days and this has really irritated the problem, so I have stopped these for the moment. So, all in all, I have had pain that varies in strength for the last 9 years and it is impacting my work – office and field based sales. Randomly, I recently purchased a car with ‘sports’ seats, and I believe this has made things worse as the seats press on my thighs, which may be compressing the issue laterally. I was wondering if you knew of an expert consultant in this area I could pay a visit to try and sort me out once and for all. I have probably seen about 6 different people, but none seemed to be an expert is this area. I’m also thinking that due to the length of time I have had this, there must be quite a bit of scar tissue, so I may need to have a surgical procedure. Any advice would be appreciated. Thanks, Steve

  39. Gina June 2, 2015 at 2:45 am #

    This is such a great thread, and the fact that it has continued on for over 2 years just goes to show how invaluable everyone’s contributions are!

    Here in the States, I feel like many doctors are behind the times when it comes to tendinosis. My chiropractor diagnosed me with PHT. He knows my history and can feel that my right tendon is much thicker and more fibrous than the one on my left side. Furthermore, I have had a spinal MRI which was negative, and my symptoms fit PHT well. We’ve ruled out ischiogluteal bursitis and piriformis syndrome.

    My question is: Has anyone had mixed feedback from an Ultrasound to diagnose this? I’ve seen two orthopedists now and both used Ultrasound to examine the tendon and said “nothing looks significant.” However, my chiropractor has always been spot-on in his diagnosis and the Drs. often wrong. Has anyone found that an MRI was needed to confirm this? Or that the imaging didn’t look “bad” even though the injury was disabling?

    One other question– has anyone else experienced hamstring weakness and scar tissue further down in the hamstring as a consequence of the PHT further up?

    • Annette June 3, 2015 at 11:05 am #

      Hi Gina,

      I’m sorry to hear you are suffering from this debilitating PHT. I couldn’t believe the pain I had with it….in both legs!! In answer to your questions, I had endless issues with getting a prognosis! I visited GP’s, Orthopaedic surgeons, Vascular surgeons and Neurologists with no success. MRI’s, CT scans and ultrasounds gave no indication of anything significant, however, the pain definitely proved otherwise! I had weakness and pain in the hamstrings, calves and feet (could not stand up on my toes for several months, found sitting down unbearable, walking painful and generally couldn’t, at that time, pin point where the pain was emanating from. As the pain became controlled I found it was coming from my sit bones…on both sides). With the help of a sports therapist I have managed the condition and have improved a great deal.

      I’m a Personal Trainer and spend my free time strength training, I have done half marathons and 10km races in the past but as I currently live and work in the middle east, spend more time in the gym. The problem started in October last year, by Christmas I was in a wheelchair and taking Lyrica as a pain relief. Once the pain was controlled I came off Lyrica and slowly got back into walking and attempting some light weights, bridges etc… For some time I found I was getting pain in my hamstrings from even the lightest weights and abdominal work but persisted and now glad I did.

      All in all it is a slow recovery, I’m at the seven month stage now and have definitely turned a corner ;). Still not running but can now clearly see I will at some stage. Later this month I have an appointment with a sports PT at Oxford Uni in the UK, am hoping to find the reason’s behind PHT and what I can do to prevent having to ever go through this again. I think the answer may be from a pelvic tilt but would prefer to have a definite diagnosis.

      I hope this is of some help to you, it is an extremely frustrating condition.

      Patience and Perseverance is the key!

      • Gina June 9, 2015 at 6:30 pm #

        Annette, thanks for your reply. It’s funny how many people I hear say the same thing– that Ultrasound in particular was of no use, and that sometimes no imaging was “positive” for injury. That being said, clearly there is a problem in the muscle or tendon that can be felt even to an outsider’s touch.

        Do you think Lyrica helped you?

        And did you do an isometric-eccentric progression of exercises along with the core/pelvic work? I’m curious to hear how you progressed in your exercises since you seem to have turned a corner. I hope you will be running again soon.

        • Anna June 9, 2015 at 11:15 pm #

          Its been 2 yrs 2 months since my initial onset. Im still not convinced its a hamstring issue rather a chronic pain/nerve issue in that area. However I am now back running, sitting for hours without flareup. Lyrica did nothing for me. I think it was time and very very gradual progression with exercise. I hope you improve quickly!

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