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
  • Hamstrings injuries often become recurrent injuries for a number of reason. We explain why here.
• 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 (see our post here on whether you should use heat, ice or meds). 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.