Improving sitting pain in Proximal Hamstring Tendinopathy

Pain with sitting can be one of the most challenging symptoms to treat in Proximal Hamstring Tendinopathy (PHT). Ironically, all the sitting I did while writing my research paper on PHT aggravated my hamstring tendon pain! For many it will settle naturally with time but for others it can become a long term issue with serious consequences for work and everyday life. I’ve met patients who have avoided sitting altogether, even standing to eat and others who perch sit on one side years after the onset of pain. This doesn’t have to be the way though, there are things we can do to improve sitting comfort and get back to normal sitting activities.

Understanding sitting pain in PHT

We think sitting is painful in PHT because it compresses the tendon and when it’s sensitive or swollen this may hurt. The common advice is therefore to reduce painful sitting in the early stages of proximal hamstring tendinopathy. This is sound advice but there are some key things to point out here;

  1. This is a short term strategy to help symptoms settle and not a long term plan.
  2. Sitting is not damaging to the tendon it’s a normal activity we all do every day. Research suggests we sit, on average, around 6 to 7 hours per day in developed countries. Surely if this was truly harmful for the hamstring tendons we’d all have PHT!?
  3. Lots of daily activities cause tendon compression, this isn’t to be feared or permanently avoided.
  4. A key concept in managing painful tendinopathy is a graded return to normal activity, sitting should be included within this.

The answer then isn’t to completely avoid sitting with PHT but to find the right amount at the right stage.

When and how to reduce sitting

During the reactive, irritable stage which is typically about first 2 to 8 weeks after onset it’s helpful to reduce sitting to comfortable levels. Even during this stage complete avoidance of sitting isn’t usually needed and can make it harder to return to sitting later on. Simple solutions can help sitting comfort during this period;

  • Break up periods of sitting by standing regularly or having a walk (the ‘StandUp’ App detailed below can help with this).
  • Select a softer seat where possible
  • Use cushions to improve comfort (see adapted pillow below)
  • Padded cycle shorts can be a useful option to wear under clothes
  • Change sitting position – slumping a little or tilting the pelvis back to place weight on the posterior part of the buttocks or thighs can help. Increasing chair height may also help by reducing hip flexion.
  • Where driving is a problem consider moving the seat forward to reduce the need to reach for the pedal and stretch the hamstrings
  • Modify or reduce other provocative activity such as stretching and running (especially uphill) which may increase tendon pain and lead to more discomfort when sat
  • Try isometric glute squeezes when sat – tighten your buttock muscles and hold for 30-40 seconds 4 or 5 reps. Tensing glute max creates a muscular cushion under the hamstring insertion and can reduce pain. Strengthening glute max can also help by increasing this size of this cushion.
  • Recognise that the pain is from pressure on sensitive tissue a little like pressing a bruise. This may not make it less painful but helps reduce the worry surrounding the pain.

When to return to normal sitting levels and how to do it

As symptoms start to settle gradually increase your sitting back to whatever is normal for you. It’s sensible for many of us to break up sitting a little and be more active during the day but ideally this should be a choice rather than something tendon pain forces you to do. If symptoms aren’t settling after 3 or 4 months (or more) it may still be possible to increase your sitting (with guidance from your physio/ health professional). They key is finding the right starting point and building from there.

This approach is known as graded exposure, we find a manageable level of sitting and gradually increase. Sitting on a variety of different surfaces and slowly introducing harder or deeper chairs (with more hip flexion) can be helpful as well. It’s all part of helping the tendon adapt and get used to sitting again. If you’re trying to build up sitting tolerance it’s best not to ‘clock watch’, focus on an activity instead like reading, relaxing, spending time with friends or watching TV.

Vicki, (AKA – @HighHamstring) very kindly shared her story of PHT on Twitter. She explained the huge impact PHT had on her life, “I didn’t sit down at all for 2 years. I lost my job…driving and my social life was impaired” and how she gradually got back into sitting, using a simple chart to guide progression with different sitting surfaces,

When I build up to 10 minutes on a surface, I included the next surface for 1 minute. When I got to 45 minutes, I stopped that surface”

Vicki’s sitting chart

Vicki has set up a Facebook Page to help others with PHT by sharing what she’s learned during her recovery.

 

There’s also an excellent Facebook Page for those looking for support after proximal hamstring surgery, these patients often find sitting painful too.

The ‘StandUp’ App

This free App was recommended by top physio Greg Savides on Twitter – @Gregthephysio. It’s actually designed to help us stand more but we can use it for a gradual return to sitting. It allows you to set a reminder to stand up after a certain time and you can programme it to remind you after as little as 5 minutes if you’re sitting tolerance is low. You can then slowly build up the time from there (to a maximum of 60 minutes).

Please note: this is a free App and we have no business association with it. Alternative Apps are available!

Beliefs matter

Pain is a very complex experience. It isn’t simply a reflection of what’s happening in our tissues and we can experience severe pain without tissue damage. Our experience of pain is influenced by a host of factors including our beliefs about pain, previous experience, stress levels, mood and how much of a threat we perceive the pain to be. Let’s be clear we’re not saying it’s all in your head but highlighting that our beliefs matter and sometimes we need to alter beliefs to help pain. For some this may involving challenging the belief that sitting is damaging for the tendon and recognising that tendons are strong, resilient structures that can adapt to activity given time. The achilles tendon, for example, manages 6 to 8 times body weight with each foot strike during running for hundreds of foot strikes per mile! Challenging beliefs around pain is difficult though and it’s best to work through this with support from a health professional as part of a comprehensive approach to hamstring tendinopathy.

Closing thoughts: Sitting pain with PHT can have a significant impact on quality of life but as symptoms settle you can safely use a gradual return to sitting and other activities you enjoy. Not being able to sit can have consequences for our mental health as well as physical wellbeing. Be sure to ask for help if you’re struggling, as ever on Running-Physio if in doubt get checked out!

Thanks to everyone for their ideas and suggestions on Twitter to help with sitting pain, they were a great help!

See our selection of PHT articles for more on Proximal Hamstring Tendinopathy.

We also have a webinar on gluteal pain and PHT for clinicians coming later this month – sign up for this here.

 

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