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Aug 20

Hamstring tendinopathy – A pain in the butt

Hamstring tendinopathy feel like pain deep in the butt at the sit bones and tends to be worse after or during running.

By Physio Marg

Hamstring tendinopathy is something we see frequently at Vital Core Physio. We often see runners pushing themselves in distance, speed or terrain and pulling up sore with a pain in the butt. 

This pain gradually builds and can persist for days. It is often worse at the beginning of exercise and later once you’ve cooled down. The pain can then start affecting other parts of daily life – climbing stairs, bending over and lifting, prolonged sitting. Even walking can be uncomfortable.  Once it’s been there a long time other areas can become sore – the hip, the back, the groin.  It really is a pain in the butt. Whilst many may think it’s a glute injury, most often it is a Proximal Hamstring tendinopathy.

What is Proximal Hamstring Tendinopathy?

We used to call this Hamstring ‘tendinitis’ or even a hamstring ‘tear’. However this gave the misconception of an acute injury that would simply settle down if you gave it rest (and lots of anti-inflammatories), or worse still you could just ‘run through it’ with painkillers.

However like everything, times have changed. We now know that unless you have been involved in a traumatic event – car accident, bike crash, or unusual sporting impact injury, the hamstring tendon injury will not simply get better with rest. Why is that?

Proximal Hamstring tendinopathy is an an over-use or degenerative injury to the tendon (the end of the muscle that inserts into the bone).

It occurs as a reaction to an increased demand on the tendon beyond its capabilities (refer to our blog on training loads), which often occur during activities such as running. Put simply – doing too much, too hard and/or too often and your tissues (in this case the hamstring tendon) can’t cope.

Proximal hamstring tendinopathy is characterised by a gradual onset of deep, localised pain where the hamstring muscles attach on to the pelvis (ischial tuberosities or ‘sit bones’), radiating down the back of the thigh. It will feel like it’s at the base of the butt cheek.

This pain is caused by irritation of the proximal (upper) hamstring tendons. The proximal hamstring tendons connect the three hamstring muscles; semimembranosus, semitendinosis, and biceps femoris. These muscles are responsible for bending the knee and extending the hip – both pretty important functions in running.

How can I get back to running without hamstring tendinopathy pain?

We understand that running is not just about fitness.

This is the single most important question we (VC physio’s) get asked.

It really depends how long you’ve had the hamstring tendinopathy for, and what sort of load (exercise, and daily activities) you are putting it under, as well as other factors such as your general health and physical capabilities.

Treatment always falls into three main phases;

1. Reducing load down to a level that the tissues can cope with. Keep in mind that may not be ‘not running’. It may instead mean running a shorter distance, different surface, pace. Or it may be some form of cross training.

2. Building up the load tolerance of the hamstring tendon and muscles which means specific strength training for that area as well as the surrounding area. Strength takes time to develop. Think of going to the gym – how many weeks do you need to go before you notice you are getting stronger or your muscles are starting to tone up? At least 6 but more likely 12. With a tendon we (scientifically) know that it will take at least 3-6 months of a consistent progressive strength program to toughen it up properly. Even after this time when it is strong the area may remain ‘tender’ to touch.

3. Putting in strategies to prevent a reoccurrence. That means structuring a better weekly and cyclic training program that takes into account short and long term goals, as well as varies for personal stress and family life. Building up you runners health IQ is essential in limiting and preventing future injuries.

Can Vital Core help me?

I’m glad you asked. The answer is YES!!!

Firstly we will find out what is important to YOU. What do you want to be able to do that you can’t right now – yes I know you want to be able run pain free, but how far? How often? Do you have an event you want to do? 
 
What does you daily life look like? How much time do you spend, sitting, standing, walking, lifting, bending? When do you get your runs in? How long have you been running for?

All these questions (and many more) will help establish a picture of how this problem started, how it is affecting you and more importantly how we are going to get rid of it once and for good.

We will then test your body to determine all the physical factors that have gone into causing this injury. Is you back stiff, your glute muscles weak, your core poor, your posture terrible?

We’ll talk through all our findings as we go so you know what’s going on and why. This is another way we help develop your running injury IQ (essential for preventing reoccurrence).

Hamstring tendinopathy is often associated with poor lower body alignment and control. we can help
Lower limb alignment plays a huge role in running.

Once we have all this, we need to (together) determine a full treatment plan. Taking into account the phases mentioned above.
That will likely include some hands on treatment and pain management strategies for home as well as your home exercise program. This program may be very simple to begin with but will become progressively more challenging as you improve over the weeks.

The plan will be explained to you and written down for you to take home and digest. Again, this builds your running injury IQ. 

Proximal hamstring tendinopathy take a really long time to fully recover, but if you stick with the plan, you WILL get there and we’ll be there by your side to help. Remember you can make an appointment online, right now.

We want you out there enjoying all that running give you.

Some interesting points on hamstring tendinopathy and recovery:

  • Factors such as age (natural changes in the body) and gender (see our blog on menopause and running) can play a part in developing tendinopathies and needs to be considered with a potentially longer recovery time as a result.
  • Further investigations (radiological imaging) are not warranted unless there has been significant trauma or something sinister is suspected. This is the reason we ask so many questions in our assessment, to treat you and your presenting signs and symptoms with imaging not likely to change your prognosis or management. In fact it can be damaging as imaging often picks up incidental (normal age related) findings that make it look a lot worse than it really is. This can cause fear – not helpful.
  • Closely monitoring symptoms during and after exercise is key to understand how best to progress through your rehabilitation.
  • Be patient and persevere! This condition can take months to overcome, with the risk of flare-ups throughout your rehabilitation. Consistency is crucial with specific and progressive exercise as best practice for management of proximal hamstring tendinopathy. 
  • Cortisone injections may have their place in the elite sporting population, however are not recommended for middle aged recreational athletes as they have been associated with degeneration progression. 
  • We have many more blog articles on running and injuries.

RunFit

RunFit is on Mondays and Tuesdays 7-8pm

Well of course we were going to talk about RunFit!

We started RunFit about 4 years ago because we were seeing the same problems over and over again with our recreational running patients.

Over the years we have built it into an 8 week progressive circuit based exercise program, running from week 2 of the school term (each term). The exercises start super simple and end – well, pretty damn hard (although they can be individually varied).

Each week there is also an educational email to help build that running IQ. But thats not all! There is also a home exercise program that is sent home via an app based exercise program software ‘Physiapp’.

It’s a really great class and has built from one class of about 6 participants to two classes a week of about 9.

It’s challenging, fun and informative.

FAQ’s about RunFit

We often get asked is if it’s suitable for blokes as well as women. Our answer is, as long as the bloke wants to run or is a runner then absolutely. It is hard enough, trust us 😉

Another question is what if I haven’t run in a long time or I’ve never run before – should I do Runfit? Firstly have an assessment with one of our physio’s. They will go through your history, find out your goals and test your body. More often then not the physio will say “Yep, join in” Sometimes through the physio might recommend one of our other classes or a home program first and encourage you to join RunFit the following term.

What if I miss a class can I make it up?

Generally no because it is a progressive course. We encourage you to do the home exercises regularly to keep building your strength and control at home.

RunFit is on Monday and Tuesday nights 7-8pm.