Hamstring Tendinopathy

What is hamstring tendinopathy?

As you might have seen in previous Q&As, tendinopathy refers to a range of structural changes that can occur throughout a tendon that may result in pain.
Our hamstring group is made up of three muscles, each with a proximal attachment site at the pelvis (and one with an attachment on the femur!) and a distal attachment onto the tibia.  Individuals can experience pain or discomfort at both the proximal and distal attachments. For today’s Q&A, we’ll focus primarily on proximal hamstring tendinopathy.
Proximal hamstring tendinopathy is often described as a deep localised pain in the buttock, which is often aggravated with sitting, driving, running (particularly sprinting) and lunging. Ultimately, it can be caused by a range of issues, however it often comes about with an increase in activities which cause compression between the proximal hamstring tendon and its attachment site on the pelvis. This increase in load exceeding the tissues capacity begins a range of changes within the tendon which can result in pain. 

I often get pain with running, are there ways to modify my training and continue running pain free?

Where possible, we want to maintain a degree of training or exercise in individuals with proximal hamstring tendon pain. Clinically, we often see that runners can tolerate slow and flatter runs. As such, if we need to reduce load through the proximal hamstring, we’ll often reduce speed/tempo work and cut down elevation.
It is important to know that we are able to effectively manage hamstring tendinopathy even in the presence of some pain with running. The running load however needs to be closely controlled and within particular pain limits.

What are some typical exercises you prescribe for proximal hamstring tendinopathy.

Exercises will vary depending on the individual and presentation, although there is a general pattern that we may follow if particular exercises are indicated. Furthermore, exercises should always be guided by a physiotherapist or qualified strength & conditioning coach. Firstly, typically prior to adding any exercises, I will look to reduce any provocative loads through the hamstring. This includes stopping any stretches through the hamstring, minising sitting, driving or any unnecessary exercises which may provoke the hamstring. In early stage rehabilitation, I may look at exercises targeting lumbopelvic control (i.e. the ability to control the position of the low back and pelvis) and hamstring strength in a neutral hip position. An example of this may include a prone hamstring curl.
This will gradually progress into more complex lumbopelvic control and hamstring strengthening or endurance exercises. An example of this may be a concentric/eccentric single leg hamstring bridge.
In later stage rehabilitation, we will possibly introduce hamstring loading exercises in greater positions of hip flexion with higher loads. This may even include plyometric exercises for the hamstring. This may include kettlebell swings or Romanian deadlifts.

What can I do to reduce the pain in sitting?

Clinically, I have found that by simply placing a cushion or towel on a chair to position the hips above the knees, many patients may reduce irritability with sitting!

How long will it take to get better?

This is difficult to answer as it can be so variable! However it is important to know that tendinopathy is often quite slow to resolve. In cases which occur in young individuals who have simply had an acute increase in load, a brief reduction in activities which provoke the tendon will often settle things quite nicely within a matter of weeks.
In chronic cases where there are multiple risk factors, it isn’t out of the question to take more than 6 months to achieve a reasonable outcome. Again, this is highly variable and depends significantly on personal circumstances.