Hamstring origin tendinopathy (or proximal hamstring tendinopathy) is a pain in the bum – literally! This occurs at the very top of the hamstrings, where all three attach into the ischium, or sitting bone. It causes pain in the crease of the butt which may radiate a little down the leg.
You may see this condition referred to as a tendonitis, tendinitis, tendinosis, tendinopathy, etc etc! They all mean very slightly different things, but the difference is so slight that someone suffering with this condition, or their therapist would only be able to tell the difference using imaging such as an MRI or ultrasound scan! Tendinopathy is an umbrella term which covers all of these conditions and so I will use that!
Symptoms of Hamstring Tendinopathy
- Aching pain in the butt crease – this may initially ease as you warm up and only come back after you stop
- Symptoms develop gradually, with no sudden moment of pain
- As the condition gets worse the pain is more constant
- Pain is usually worse on sudden bursts of speed
- The hamstrings may feel stiff or tight – especially in the mornings or after long periods of inactivity
- Tenderness when pressing on the sit bone and area just below it
- Discomfort (or in worse cases- pain) in the same area when contracting the hamstrings against resistance (i.e. bending the knee or extending the hip)
- Sometimes the sciatic nerve can become irritated and symptoms may refer down into the hamstring muscles.
What is it?
Proximal hamstring origin tendinopathy is a degenerative condition of the hamstring tendon. All three hamstrings originate from the ischium, or sit bones, which you can feel at the base of the pelvis.
Tendinopathy conditions can occur in any tendon. They are overuse injuries by nature, which means they develop due to additional stresses being placed on a tendon, which is not necessarily strong enough to deal with that added load. In response, the fibres in the tendon develop tiny microtears. Whilst the body attempts to heal this, we often don’t give it a chance and carry on training, increasing the load and creating more tears, without allowing full healing in between. It has been thought previously that these conditions are inflammatory in nature (hence the suffix ‘itis’), but studies have shown that this is not the case.
What Causes Hamstring Origin Tendinopathies?
As touched upon above, overuse is the main culprit. But there are many ways you can overuse your hamstring tendon!
- Running too much, too quickly.
This is common in new runners and those who have started training for a race. Your body and all of its structures need time to develop when new demands are placed on them. If it is not given this gradual increase then damage occurs.
- Muscle imbalances
If your training program isn’t to blame, then it could be down to muscle imbalances. A common one is that the Glute Max isn’t working efficiently and so some of it’s workload in extending the hip joint is being passed on to the hamstrings.
- Inflexible / weak hamstrings
Weak hamstrings can be strengthened, both concentrically and eccentrically to help them cope with the demands of running. Tight hamstrings should be stretched regularly.
Treating Hamstring Tendinopathies
As with most running related overuse injuries to first course of action when treating the condition is to rest from running and any other sports or activities which seem to flare it up. Applying ice can help ease pain, although personally I don’t think it’s an important aspect of treatment with this condition. If you do choose to apply ice, then 10 minutes at a time is enough, every 2-3 hours or after anything which aggravates the condition.
Obviously at this point I would suggest visiting a sports injury professional for an assessment of your injury. As well as determining what the injury is, they can help with working out why it developed. If you know this, you’re half way towards treating the problem.
Sports massage is also excellent for this condition to help loosen tight hamstrings, friction the tendon to increase blood flow and initiate a healing response. A therapist may also use other treatments such as ultrasound or laser and kinesio taping.
Stretch the hamstrings several times a day in whatever position feels best to you. To target the higher portion of the hamstrings a hamstring stretch with the knee bent is ideal:
- Stand with one foot on the floor and the other foot up on a chair seat
- Bend the knee to around a 45 degree angle
- Keep the back straight and lean forwards from the hips until a stretch is felt in the hamstrings.
- Hold for 30 seconds, rest and repeat two more times.
- Do this at least 3 times a day, more if you can.
Don’t stretch into pain – it should feel like a strong stretching or pulling feeling, which may feel at it’s strongest around the upper attachment. If it feels like a pain, take it back a step to reduce the stress on the tendon.
You should find after a bit of rest and stretching that the symptoms start to ease and you don’t feel the pain on daily activities. For mild cases this may only take a few days. For more severe cases you might need a couple of weeks. In this time, if contracting the hamstrings is still uncomfortable then I wouldn’t recommend hamstring strengthening exercises yet. But you can do glute exercises.
So, if you think that part of your problem may be an imbalance between your hamstrings and glute, your aim should be to get the glutes firing stronger and more readily, to take some of the strain off the hamstrings. Glute Max is the one we are really aiming at here as it extends the hip with the hamstrings.
It is well known that Glute Max can become inhibited due to tight hip flexor muscles at the front of the hip. So your first task is to check this and if they are tight, get to stretching them! A Thomas test is used to see if the hip flexors are tight. To do this, perch yourself on the very end of a bed / couch (ideally a high one) and pull one knee in to your chest, hugging it in as tight as you can. Then roll yourself back on to the couch so you are laying flat on your back, keeping the knee pulled in. Relax the other leg and let it hang wherever is natural. There are two hip flexor muscles which could be tight – Iliopsoas (the short one) and Rectus Femoris (the long one). If Iliopsoas is short you will notice that the thigh does not rest down flat on the couch and the knee end is lifted up a little. If Rectus Femoris is tight, you will see that the knee is not bent to a right angle -it is more straight than that.
Have a look at both sides, or get someone to help as that’s often easier to see what’s going on. It is possible that both are tight, or just one and it may be that one side is tighter than the other and not always the side that corresponds with your hamstring pain! That doesn’t mean it’s not involved – so still treat it with regular hip flexor stretches:
- Kneel on the floor with one knee on the floor and the other foot out in front of you.
- To stretch Iliopsoas, make sure the top of the back foot is flat along the floor.
- Tilt your pelvis backwards – imagine you are tucking your tailbone underneath you
- You may already feel a stretch in the front of the hip, but if not just shift your body weight forwards until you do.
- Hold for 30 seconds, rest and repeat two more times.
- To stretch Rectus Femoris, simply tuck the toes of the back foot underneath your foot to get a little more knee flexion. You should feel the stretch move a little down the thigh.
So as well as stretching the opposing muscle group, you can also get Glute Max firing with a simple exercise:
- Lay on your front
- Start by practising squeezing both bum cheeks! Hold each squeeze for 3 seconds, rest and repeat 10 times.
- Then make it a little harder by alternating left, right, left, right.
- At this point many people realise that they have one side which is stronger than the other!
Once the Glute Max is working, try putting this in a slightly more functional exercise:
- Still on your front
- Bend one knee to shorten the hamstrings and reduce the effect they can have on this movement.
- Squeeze the bum muscles on the same side and then lift the thigh up off the floor.
- Don’t worry about holding it – this exercise is all about the contraction.
- Rest and then repeat – squeeze and lift!
Again you can progress this to more functional exercises such as Bridges where you squeeze the bum muscles and then lift the hips off the floor.
Once you get to the point where there is no hamstring pain on a daily basis, it’s time to start strengthening the them.
Start with rehab band exercises such as resisted knee flexion which isolates the hamstrings and also more co-contraction exercises such as hip extensions, being sure to use the glutes to help out. Start with low reps such as 2 sets of 12-15 and gradually increase reps and resistance, provided you stay pain free.
To progress from this, you can use resistance machines in the gym such as the leg curl. Once you can see improvement in your hamstring strength and before returning to running, add in some eccentric strengthening with exercises like deadlifts, good mornings and Nordic hamstring curls.
Return to Running
The final step of rehabilitation is the return to running phase. This should only be attempted when everything above is pain free and improvements have been made in strength and flexibility. Also get a coach or experienced runner to check your program to see if any training errors could have been to blame.
When you are ready to start running again, a gentle, steady paced and short run is the first thing to try. Start with 10-15 minutes, rest for 2-3 days and provided there is no pain try the same distance again. If all is still ok you can start to gradually increase the time and distance spent running.
Always continue with rehabilitation exercises even when you are back to full training to prevent a relapse of the injury.