How to Get Back Into Running Without Getting Patella Tendonitis Again

What is Proximal Hamstring Tendinopathy?

Proximal hamstring tendinopathy (PHT) is a painful condition affecting the hamstring tendons where they attach to the ischium of the pelvis. Many people with this condition often describe lower buttock pain that eases during exercise but usually returns.

It isn't necessarily what you first think of when somebody mentions hamstring injuries.

When most people think of running-related hamstring injuries, they picture the classic image of a sprinter pulling up sharply mid-race, as if hit by a sniper shot. This kind of acute hamstring tear is indeed the most common type of injury to the hamstring muscle group.

However, a less well-known but surprisingly common injury, especially amongst endurance athletes (rather than sprinters) is proximal hamstring tendinopathy. This chronic injury is often difficult to rehabilitate, frequently resulting in long and frustrating interruptions in run training.

In comparison to acute hamstring muscle tears, there is little research into proximal hamstring tendinopathy (also known ashigh hamstring tendinopathy) in runners.

In this article, I'll take a look at what the research tells us, in combination with my own anecdotal observations having worked with many runners suffering from this specific injury over recent years.

HAMSTRING TENDON REHAB EXERCISES >>
Free Download [PDF]

Anatomy of the Hamstring Muscles

There are actually three hamstring muscles at the back of each of your thighs: semitendinosus, semimembranosus and biceps femoris with its long and short heads. At the top of the muscle group, while the short head of biceps femoris attaches to the femur, all the other hamstring muscles share a common point of origin on the ischial tuberosity (sitting bones) of the pelvis. This point of attachment sits deep beneath the bottom part gluteus maximus (the bigger of your butt muscles).

At the bottom of the hamstrings, around the back of the knee, both semitendinosus and semimembranosus attach to the medial tibia, while biceps femoris attaches distally close to the fibular head, towards the outside of the knee.

Like all skeletal muscles, the individual hamstring muscles act to produce motion in all three planes of motion. However, the linear orientation of their fibres and lever arms at the hip and knee make them most effective in the sagittal (back and forth) plane.

When I was taught anatomy at school, the hamstring muscle actions were described at isolated joints, in an open-chain (non-weight bearing) situation. I was taught that the text-book function of the hamstrings is to contract concentrically to produce hip extension and knee flexion.

However, with the hamstrings being a two-joint muscle group (crossing hip and knee), when we run there are other considerations to take into account, especially during stance phase. During this phase, the foot is anchored to the ground by our body weight creating a closed chain environment. As the hamstrings contract with glute max to create hip extension, propelling us forwards they also create an extension moment at the knee… rather than knee flexion as we learnt at school!

More about this counterintuitive muscle function in a future post!

Symptoms of Proximal Hamstring Tendinopathy

The location of pain for runners suffering from proximal hamstring tendinopathy is specifically around the ischial tuberosity of the pelvis (the sit bones). Pain in this region is often described as 'deep buttock pain', or 'high hamstring pain'.

As a quick side-note: proximal hamstring tendinopathy is classified as a tendinopathy rather than a tendonitis, due to it's degenerative nature rather than being an inflammatory pathology.

Runners suffering with high hamstring tendinopathy will complain of buttock pain around the hamstring insertion area, especially when running at faster paces, and running uphill.

The pain of proximal hamstring tendinopathy is usually an intense ache in nature, rather than being sharp or stabbing as a muscular tear would be.

Occasionally, the sciatic nerve can also be affected, as it lies fairly close to the common hamstring tendon. This can cause referred pain into the posterior thigh. Once aggravated, direct pressure on the hamstring tendon can be painful, thus sitting on solid surfaces can also become uncomfortable, as can direct manual palpation and pressing onto the ischial tuberosity.

Can You Run With High Hamstring Tendinopathy?

It is possible to continue running with proximal hamstring tendinopathy. However, you may need to make alterations to your training plan. Avoid hill reps and speed work, as these types of running usually aggravate an irritable hamstring tendon.

The inevitable question when it comes to an annoying niggling injury like proximal hamstring tendinopathy is whether or not you can run through the injury. I've seen lots of runners successfully manage run with this injury, and continue training, perhaps for an upcoming marathon, simply by adapting their marathon training plan a little.

Knowing that speed work, and hill running are both usually aggravating factors for high hamstring tendinopathy, sufferers should consider removing these from their running training schedule, to prevent flare-ups. Stick to easy paced running, and working on building your aerobic base.

When it comes to running style, avoid the temptation to stride-out, as it's this increased hip flexion that creates the loaded compression of the hamstring tendon that may exacerbate your tendinopathy.

Instead, focus on increasing your running cadence and making short-quick strides for the given pace.

Here's an article full of running technique tips, which will explain how to increase your cadence, and why it's important to do so: How to Increase Your Running Cadence

I've seen conscious simple changes to running technique make a huge difference to the symptoms of runners with proximal hamstring tendinopathy, to the degree that it allows them to continue training, albeit in a modified fashion.

Proximal Hamstring Tendinopathy Diagnosis

As with all running injuries, if you're concerned that you may be suffering from proximal hamstring tendinopathy, it's important to seek face-to-face medical advice, rather than simply consulting Dr Google, and coming to your own conclusions (oh, the irony!).

There are a number of different potential causes for the type of deep buttock pain that high hamstring tendinopathy sufferers know all too well. Piriformis syndrome, lower back injuries, and pelvic stress fractures, can all create a similar set of symptoms, and form a non-exhaustive list of differential diagnoses for proximal hamstring tendinopathy.

It's not unusual for me to meet runners who have has their high hamstring tendinopathy misdiagnosed for piriformis syndrome, and vice versa… which has lead to ineffective rehab, and an extended period of rest from running. So frustrating!

This is why an MRI scan will often be used to support the diagnosis once and for all.

If your physio suspects you might be suffering from high hamstring tendinopathy, there are of course a number of manual tests they may use to confirm their hypothesis.

Testing For Proximal Hamstring Tendinopathy

In January of 2012 Cacchio et al., published a paper looking at the reliability and validity of three pain provocation tests used for the diagnosis of chronic proximal hamstring tendinopathy. Taking into account the need for further assessment of the three tests used in the study (listed and described below), the authors concluded that the chosen tests represent a valid, reliable means of testing for Proximal Hamstring Tendinopathy.

The three tests they used in the study are as follows:

Puranen-Orava Test

In the Puranen-Orava test for proximal hamstring tendinopathy, the subject actively stretches the hamstring muscles in the standing position with the hip flexed at about 90°. The knee on the testing side is fully extended and the foot is up on a support

Bent Knee Stretch Test

The bent knee stretch test for proximal hamstring tendinopathy is performed with the patient lying supine (on their back). The hip and knee of the symptomatic leg are maximally flexed, and the examiner slowly straightens the knee.

Modified Bent Knee Stretch Test

In this test for proximal hamstring tendinopathy, the patient lies in the supine position with the legs fully extended; the examiner grasps the symptomatic leg behind the heel with one hand and at the knee with the other hand, maximally flexes the hip and knee, and then rapidly straightens the knee.

As mentioned earlier, MRI and ultrasound imaging provides a great diagnostic resource. MRI, in particular, can identify tendon thickening, tearing, inflammation, and swelling in the bone at the ischial tuberosity.

Proximal Hamstring Tendinopathy Treatment

Compared to other more common running injuries, comprehensive literature on proximal hamstring tendinopathy is fairly limited. However, in 2005 Frederickson et al., at Stanford University published an insightful paper reviewing treatment and rehabilitation guidelines for high hamstring tendinopathy in runners .

Following thorough assessment and diagnosis confirmed by MRI, Frederickson's group evaluated injured runners for core strength, hamstring flexibility and pelvic stability. The following treatment options are recommended in their paper:

Soft Tissue Treatment, Manual Therapy & Stretching

Hands-on treatments providing soft tissue mobilisations to break up scar tissue and adhesions can be useful, as can transverse frictions to the affected tendon. Care should, however, be taken not to apply direct pressure to the ischial tuberosity itself. This sort of soft tissue work is complementary to a gradual introduction to regular hamstring stretching.

If upon assessment, pelvic misalignment (anterior innominate rotation in particular) is identified, manual manipulation to restore the alignment of the pelvic innominate bones is often useful in restoring proper hamstring function. The work of Cibulka et al., is mentioned, as they reported in their 1986 study that after one manual treatment to realign the pelvis, isokinetic hamstring peak torque was seen to increase by 21.5%.

The question, of course, must always be asked – where does the imbalance come from that caused the pelvic misalignment…?

Exercises for High Hamstring Tendinopathy

Yamamoto is cited for his 1993 work identifying hamstring-to-quads strength ratio (amongst other factors) as a variable affecting the risk of hamstring injury in runners. Although it's not clear whether his findings also apply to proximal hamstring tendinopathy, Frederickson's group identify hamstring strengthening as an important part of their rehabilitation guidelines.

They suggest that the progression of targeted hamstring exercises should go as follows:

• Isometric hold exercise:
  90 Degree Hamstring Bridge Holds
• Single leg exercises:
  Glute March Drill
  Single Leg Hamstring Catch
• Loading through range:
  Swiss Ball Hamstring Curls
  Runner's Arabesque (only when you're ready to load into hip flexion)

For full details of sets and reps, feel free to download the rehab exercises worksheet linked below:

HAMSTRING TENDON REHAB EXERCISES >>
Free Download [PDF]

Core Strength & Pelvic Posture Correction – The Key Perhaps?

Hands-on treatments, stretching and progressive strengthening are all important components of any good rehabilitation plan for proximal hamstring tendinopathy. However, in my experience, I find the following core strengthening element to be the key to a successful outcome .

The paper by Frederickson et al., identifies the work ofSherry and Best (2004) in emphasising the vital importance of trunk stabilisation exercises in the successful rehabilitation of hamstring injuries. The emphasis is put on core strength exercises which help the athlete maintain a desired neutral pelvic position throughout dynamic movements.

It's my experience that many of the athletes I've worked with who suffer from high hamstring tendinopathy, or recurrent hamstring strains, present displaying poor ability to control their pelvic position throughout the performance of functional movements for their sport.

Particularly, the tendency seems to be for them to fall into an anterior pelvic tilt / innominate rotation. Of course, this will put the hamstring in a position where they are chronically held on tension.

This article on Gluteal Inhibition further explains the contributing soft tissue imbalances that lead to this issue.

Re-educating proper pelvic position throughout movement, and working to correct imbalances which predispose an athlete to poor pelvic posture should, in my opinion, take equal, if not increased precedence over elements of the rehab programme such as eccentric hamstring strengthening protocols.

Below is an example of one of the various exercises I give athletes to help address imbalances which affect their pelvic posture in running gait.

Related >> Three Exercises You Should Avoid
During High Hamstring Tendinopathy Rehab

Each athlete's injury is, of course, different, but the guidelines above hopefully provide food for thought and some direction in the treatment and rehabilitation of such cases.

There are other treatment options available, in addition to the conservative options mentioned above. It's not the remit of this article however to discuss options such as corticosteroid injections, shockwave therapy and surgical interventions.

Return to Running After Proximal Hamstring Tendinopathy

As with all running injuries, it is important to take a very gradual approach to your return to running after proximal hamstring tendinopathy. One of the biggest errors made by athletes is giving up on their rehab exercises as running is re-introduced to the programme. Hamstring problems have a nasty habit of becoming recurrent. It's always my advice that once an athlete has suffered this sort of injury once, and successfully recovered, their rehab exercises become their maintenance exercises.

Here's a useful programme to use to help ensure a safe re-introduction to running.

Last updated on March 2nd, 2021.

snodgrassspect1985.blogspot.com

Source: https://www.kinetic-revolution.com/proximal-hamstring-tendinopathy/