As a runner the desire to run never really leaves you. When a Proximal Hamstring Tendinopathy stopped me running my drive to work became a bit of a daily torture! Every morning I'd see runners cruising along the cliff top paths, building up a sweat in the early morning sun. I was so jealous, my heart would sink and my hamstring would twinge, just to remind me it was there! But that was in the past…now I've rehabbed, I'm pain free and ready to hit the road. So how do you return to running after Proximal Hamstring Tendinopathy?..
Ah, you wanted more details than that? Oh alright then…
Are you ready to run?
The first question has to be are you ready to return to running? Your Physio/ health professional should guide you with this as it can be a complex decision. Running requires tendons to manage quite high levels of load and to utilise part of their function known as the Stretch-Shortening-Cycle (SSC). The SSC involves the tendon storing and releasing energy, behaving like a complex, viscoelastic spring. If started too early this can aggravate tendon pain, especially if there is insufficient muscle strength or if the tendon is in a reactive state.
There should be no pain at rest and the tendon should be able to tolerate a few functional tests. Try a simple unweighted drop lunge with the painful leg in front (see below). This places some compression on the hamstring tendon and should ideally be pain free, indicating the tendon is able to tolerate some compressive load.
Muscle strength is vital for good tendon health and function. Compare your 10 rep max (maximal weight you can lift 10 times with good technique) for the prone hamstring curl. Your strength should be equal left and right. If you don't have access to equipment try doing repeated single leg bridges with the knee flexed around 30-40 degrees, again compare left and right.
Ultimately though the best test of tolerance to running is to run! In the early stages of my PHT even running across a road hurt! It was clearly too early to hit the trails again! Try a gently jog around the block and see how the tendon responds. Bear in mind that tendon response isn't always immediate – you need to see how it is in the 24-48 hours after exercise. Start small, 5-10 minutes on the treadmill, and see how it responds.
Should it be pain free when running?
Ideally you shouldn't have pain when running but in some cases it is ok to run with mild symptoms. Again be guided by your Physio! Silbernagel et al. (2007) studied the effects of continuing sport on patients with achilles tendinopathy. They found that those that continued sport during rehab recovered as well as those that didn't, providing they monitored their pain. There were even some specific strength benefits associated with continuing sport. The guide they used was based on scoring pain out of 10, where 0 is no pain and 10 is the worst pain imaginable. Patients were allowed to continue sports providing symptoms were less than 5 out of 10 during exercise and settled after so there were no additional symptoms the following morning.
Picture source Thomeé (1997)
There is no research I'm aware of specific to PHT on this so I would view these results with caution. Also, from working with runners, trying to run with 4 or 5 out of 10 pain is not easy and often results in a flare up. Below 3 out of 10 may be a more realistic guide and is similar to that used by Kongsgaard et al. (2010) who studied patellar tendinopathy.
There's a runners habit you need to be aware of too – the arbitrary distance run…this is where we pick a distance (often out of thin air) and decide to run it, regardless of pain, weather or an impending apocalypse! I made this mistake myself early in my rehab, for some reason I decided I would run a 6km route. Why 6km I don't know! My pain was a manageable 2 or 3 out of 10 during the run but remained flared up for 6 days after! It was only after this that I realised I really did need to go right back to very short runs and monitor symptoms rather than just pick a number out of the air!
I started again with 5 minutes on the treadmill. When symptoms didn't increase I progressed to 10. For a couple of weeks I was stuck on 20 minutes, anything more aggravated symptoms. From mid April on though I was able to progress more consistently. Over a period of around 10 weeks I increased my mileage to 7 miles, which I can now manage completely pain free. In the early runs there was some symptoms during the run but once I'd found my limits those symptoms settled within a few minutes after the run.
If you can't run without symptoms flaring up then you may need more work to settle pain and build strength first. Ask yor physio for help with this and see our previous PHT articles for details.
Scheduling running and rehab
It's important to continue rehab during your return to running even if symptom free. Strength work will improve the muscle and tendon's ability to manage load. This load capacity can reduce if strength work isn't continued so it is sensible to make these exercises a routine part of yor strength and conditioning work.
Rehab exercises and running will both load the tendon and can influence each other. Research has suggested muscle performance can be reduced after running but returns to near normal values after 48 hours. Likewise strength work prior to running is likely to be detrimental to your running and potentially lead to overload of the tendon. Magnusson et al. (2010) found there was a net reduction in collagen synthesis for 36 hours after loading. Where possible leave at least 24 hours between rehab and running, especially with longer runs. Here are a few potential schedules;
Modify your running to manage tendon load
Running isn't a set thing. Some either think you run, or you don't run. This isn't really true, there are a host of variables you can change to allow you to run with minimal pain and to reduce tendon load. With PHT there are 3 keys things to cut out initially – hill running, speed work and over-striding – all are likely increase load on the hamstring tendon. Then there are the obvious variables – distance, frequency and pace – how far, how often, how fast. In addition to this you can change running surface, running form (try to reduce stride length and avoid excess trunk flexion) or try a run/ walk pattern. You may even find the time of day that you run influences your pain – symptoms are often worse in the morning so an afternoon run is easier.
All in all it's a case of trial and error to find a comfortable route over a comfortable distance at a comfortable pace.
My weakness in this is the hills. I'm very lucky, through my bedroom window I can see the South Downs. But when the flowers all burst into bloom and the fields were a bright, blanket of yellow I simply couldn't resist! The only issue is it's all hills! The solution was a run/ walk pattern, running the flat parts and walking up the hills. I managed it symptom free and was rewarded with stunning views;
Be careful to progress your mileage and speed gradually. You may want to set a baseline (how far you can run without any symptoms) and increase by around 10% per week depending on your symptoms. When symptoms have resolved and you have reached your target distance then work on speed or hill work over a short distance before building up. For more on this see our comprehensive article on returning to running after injury.
Keep on top of things that aggravate your pain
Running is far from the only thing that will aggravate symptoms of PHT. Any activities that lead to high levels of compressive or tensile load can cause pain that may well linger and affect your running. The main culprit for me was sitting, which compresses the tendon. Midway through the tendinopathy I was stuck in my car for 4 hours after Brighton was struck by a blizzard. It was painful for days afterwards and even walking was uncomfortable.
Avoid long periods of sitting or driving, don't be tempted to stretch the hamstring and try to modify activities that increase your pain.
Closing thoughts: a graded return to running after PHT is a valuable and rewarding part of your rehab but it may not be the end of it. For many cases progressing rehab to include functional strength exercises and addressing movement dysfunction will be helpful in preventing reoccurrence. If you are a high mileage runner or plan to include lots of speed work or hill running in your training I recommend a more comprehensive approach to rehab.
Your Physio should guide you through the rehab process for tendinopathy. PHT can be complex and challenging – as ever on RunningPhysio if in doubt get checked out!