Lower back and buttock pain Archives • Page 3 of 8 • Sports Injury

Hamstrings tendinopathy – frustrating but fixable

Hamstrings tendinopathy most commonly affects the upper hamstrings tendon (known as “Proximal Hamstrings tendinopathy”) just below the Ischial Tuberosity (aka. the “sit bone”).

The hamstrings, or “hammy”, also has a number of tendons behind the knee which can be affected by tendinopathy, known as “Distal Hamstrings tendinopathy”.

It’s usually a non inflammatory reaction so anti-inflammatory meds will dull the pain but not help the recovery.

This condition tends to move slowly, gradually worsening over weeks or months and improving over a similar time course. It means you should stick to a rehab approach for 3-4 weeks at a time. Then you can decide if it’s helpful or needs revising.

BEST TREATMENT OPTIONS FOR A FAST RECOVERY FROM HAMMY PAIN

To help the tendon recover, it needs DAILY activity to provide some loading but avoid strong contractions, fast movements or stretching positions
- The tendon reacts positively to consistent loading, with the loading tolerance gradually increasing as the tendon recovers
- Any loading outside of the current tolerance, either too much or too little, can cause symptoms. Overload can be due to strong forces, such as lifting too much weight, or rapid force generation, such as jumping or sprinting
Identifying the cause is the key to a successful recovery
- Common causes include a loss of hip extension (leg moving behind you) or a loss of power at the ankle (reduced push off force due to issues like a sore toe, Plantarfasciitis or Achilles tendinopathy)
- The tendon capacity can be improved with rehab and general training but the risk of a recurrence of tendinopathy remains heightened as long as the underlying cause/s are unchanged
- Depending on the cause and reasons behind it, you may be able to fix the causal issue. Otherwise you’ll need to reduce its impact on hamstrings loading by training specific areas to compensate for the deficit
Other conditions can mimic Hamstrings tendinopathy but their symptoms will respond differently to certain activities. They also require a different rehab plan
- Ischial bursitis and Sacrotuberous Ligament irritation are two injuries associated with the same area of pain and similar causes of aggravation
  - They’ll both feel worse after loading in lengthened positions, such as walking up a steep hill
- However these injuries require completely different rehab and restrictions

TREATMENT MYTHS THAT CAN SLOW YOUR RECOVERY

Stretching will actually make it worse!
- The tendon doesn’t react well to sustained stretch, even though it may feel good at the time
Exercises are helpful for recovery, but performed in the wrong phase, can make it worse
- For example, deadlifts are great for strength but cause excessive aggravation in the early phase
- Hopping is great for power but will only help in the late phase recovery
- Be wary of “the right exercise”, as recommended by a friend or the web, performed at the wrong time in your recovery
Ice packs or anti-inflammatory meds can be helpful to settle symptoms. But they give a false sense of improvement despite not contributing to tendon healing

Here’s an example of a good early phase exercise to provide some load to the tendon without irritating it:

WHAT ELSE COULD IT BE?

Hip impingement
- Impingement can cause a deep dull buttock pain that may be mistaken for a hamstrings tendon issue. Both impingement and hamstrings tendinopathy are aggravated by running and hip loading. One differentiating factor is that hamstrings tendinopathies are often painful with direct pressure, like during on a hard bench seat.
Hip labral tear
- Similar to impingement, this condition classically causes pain at the front of the hip. However in some cases it may refer pain to the buttock. A sharp catching pain is an indicator that you may have a labral issue rather than a hammy issue.
Hip osteoarthritis
- Hip OA is more painful after prolonged rest, similar to a hamstrings tendinopathy. However OA will cause a loss of range in the hip and general stiffness.
Deep hip rotator overload
- This muscle fatigue issue affects the smaller muscles surrounding the hip joint. It causes an ache and stiffness after activity and prolonged rest. It may coexist with hamstrings tendinopathy and can be addressed with massage or trigger point work.

Gluteal tendinopathy – symptoms, causes & answers

Gluteal tendinopathy symptoms include pain on the lateral (outside) aspect of the hip, often felt during exercise or walking. Pain can also be felt when lying on either side or on standing after prolonged sitting.

This tendon condition can occur on its own but is more commonly seen in conjunction with other conditions, such as hip osteoarthritis and trochanteric bursitis.

It tends to be linked closely with reduced strength and as such, it is more prevalent with older age groups. The strength deficit leads to poor control of hip rotation, which in turn tightens and overloads the Gluteal tendon.

Symptoms of gluteal tendinopathy

Symptoms of gluteal tendinopathy can be varied but there are some common elements. Pain on the outside of the hip is by far the most common complaint.

Symptoms can also include a dull constant ache or a painful snapping sensation in the same area but won’t include pins & needles or numbness – these are more likely to be associated with spinal nerve compromise or Lateral Femoral Cutaneous Nerve injuries.

Pain from gluteal tendinopathy is aggravated by running, walking (particularly walking downstairs) and side lying in bed. But it can also be stirred up by activities such as swimming due to the kicking action.

What causes gluteal tendinopathy?

The direct cause of gluteal tendinopathy is an overload of forces on the tendon. This can come from too much prolonged loading (like a very long day of hiking) but is more commonly associated with repeated spikes in loading (from a combination of rapid stretch and “shock loading” from poor muscle control).

When the muscle becomes fatigued, or leg stability is compromised, the leg rotates inwards quickly on landing. This causes a sudden pull on the tendon, which in turn creates an acute inflammatory reaction.

Over time, this reaction accrues and begins to cause pain. And that’s where the downwards spiral begins…

The ability to maintain strength in the hip muscles becomes limited by pain inhibition of muscles in the area. Basically the brain won’t fully activate the muscles if it thinks that will cause pain, so the pain “inhibits” muscle function.

That inhibited muscle function means that the rotation on landing is even more rapid and poorly controlled, creating a more significant reaction on the tendon. And so the cycle continues….

What is the best treatment for gluteal tendinopathy?

The biggest issue with making progress and fixing gluteal tendinopathy is trying to break the cycle of pain and inhibition.

Anti inflammatory meds can help make early progress by reducing pain and improve muscle recruitment during exercises. That can allow you to begin to rebuild strength around the hip.

If you’re sensitive to meds or who prefer to avoid them, you can relieve symptoms with a non-medicated heat rub (eg. Dencorub) which can be quite effective at blocking out pain and improving muscle function.

You’ll need to select strength work that doesn’t cause pain and can be performed with good technique. My preferences are, in no particular order:

Double leg hip thrust or hip bridge
Sustained wall sit
Sumo deadlift
Pallof press, on single or double leg
Crab walk with ankle band

These exercise can build strength in safe positions while avoiding symptoms. Exercises to avoid, due to their likelihood of irritating the tendon, include:

Lunges
Single leg squats
Step up or down
Any hopping or jumping (particularly during the earthly phase of rehab)

Running can still be an option but it’ll be safer if you can break it up into a run:walk format. Run until BEFORE the pain starts, then take a walk to avoid accruing fatigue, then run again and repeat. The run time is case-specific but the walk can typically be 2-4 minutes (shorter timeframe for more experienced runners).

Don’t get caught out by these myths

This condition resolves completely in almost every case although it can be quite stubborn and slow to resolve. Don’t get frustrated and return to full loading prematurely. Just be patient.

A cortisone injection may seem like a quick fix but it’ll only be successful if the underlying cause has been found and fixed (such as a single bout of overload, like an ultramarathon). It can be helpful to start your exercise program without pain but it’s a limited window to attack your exercises, not a cute in itself.

Supportive shoes and/or orthotics can be helpful for some but they’re not a guaranteed solution for all. They’ll only be successful if poor rotational control of the leg is the major factor in your causative biomechanics. If it’s a result of the pain and pain inhibition cycle, it’ll only provide limited relief.