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Proximal Hamstring Tendinopathy - A real pain in the butt

Are you an older athlete with buttock pain? Do lunges or hill running stir things up? Are you unable to work or drive without sitting pain? You may have proximal hamstring tendinopathy – and if you’ve been stretching your hamstrings to alleviate the pain – stop now!

What is Proximal Hamstring Tendinopathy?

Proximal hamstring tendinopathy (PHT) is a condition of painful tendon changes in the hamstring tendons where they attach to the pelvis. Patients with this condition often present with well localised lower buttock pain that warms up with activity but which may return afterwards, often lasting for several days. Importantly, in athletes, pain levels clearly correspond to changes in the volume and intensity of training. Compression of the hamstring where it attaches seems to be the key: stirred up by changes in training or by stretching the hamstrings, and then further aggravated with sustained sitting (on the tendon). Although often quick to aggravate, tendon pain can take quite a while to settle and will require strengthening and modified training. But the good news is that tendons are strong and adaptable and rehabilitation is supported by good quality evidence.

Why have I developed this problem?

As with so many musculoskeletal pathologies, PHT is largely determined by “what you have” (intrinsic factors) and “what you do with it” (extrinsic factors)

“Intrinsic” risk factors are the things we’re often stuck with! And the more risk factors we have the greater the impact. These include increasing age, our genetics and family history, as well as the impact of hormonal changes at menopause, some auto immune conditions and diabetes.

“Extrinsic” risk factors, including training errors, are more modifiable. Usually, pain follows a provocative change in training: for example, an increase in hill running or speed work, extra training sessions (and reduced recovery) or an increase in overall distance. In the older population, pain could follow unaccustomed power walking. What really matters is if these changes occur suddenly and/or how quickly you add high forces such as hill sprints. A change in the gym can also have big consequences: significant compressive loads on the tendon can occur with the sudden addition of deep and heavy squats or dead-lifts, or with strong hamstring stretching. Once the tendon is painful, a driving holiday or time spent on a hard chair can really stir things up.

How do I manage the pain?

Researchers in the field agree on several key points:

  • Some athletes need a short time away from their sport ,perhaps keeping fit with pain-free cross training. But too much rest actually decreases the ability of the tendon to cope with load.
  • Most people with PHT don’t need to stop their sport completely. They just need to get their pain more manageable. With slower running, a shortened stride length (which also increases co – activation of the gluteals) and avoidance of hills, many runners can continue to train. Gym junkies and cross fitters can reduce the depth and weight of their squats and dead lifts.
  • As there is always a risk of flare up, avoid training into significant pain (maybe a 2-3/10). The key is to closely monitor symptoms for any aggravation and train at a level where you have an increase in pain for no longer than 24 hours after exercise.
  • Allow yourself as much as 48 hours between training sessions as tendons require loading – and then a recovery period in order to repair.
  • Avoid compressive hip flexion: that means less time doing lunges, deadlifts and stretching your hamstrings. It also means less time sitting, and when you do – avoiding hard seats and using a posture wedge chair cushion to ensure your hips are always higher than your knees.
  • Exercise is the best treatment for tendon pain.
  • Isometric strengthening is often a good way to start the rehabilitation process. In isometric exercise, the muscles perform work but there is no joint movement, and it appears to both reduce pain and provide temporary increases in strength to protect the tendon whilst training.
  • The addition of a progressive weighted hamstring strengthening program, implemented once pain has begun to settle, improves the tendons ability to take load. Higher training loads are added carefully when appropriate.
  • Persevere: even with the best rehabilitation, recovery may take several months!

Assessment of the intrinsic and extrinsic contributions to the development of PHT, and the careful rehabilitation of this condition takes care and attention to detail. No wonder that many self guided attempts fall short of the mark. An assessment by an APA Sports Physiotherapist or Sports and Exercise Physician may be the best way to get the ball rolling.

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