by Jennie Hansen, QT2 Systems

Ed. Note—last month, we introduced high hamstring tendinopathies and began our explanation of how to recover from them. Today we complete the article with suggestions for returning to full training load, and how to fix the underlying problem that got you here in the first place!

Last time, we left off while discussing the phases of treatment for high hamstring tendinopathies, and we mentioned eccentric muscle contractions. What’s the deal with eccentrics? Eccentric exercises are those in which a muscle is contracting while lengthening. So, if you think of doing a hamstring curl while laying on your stomach on a machine, the eccentric portion of this exercise for the hamstring would be when you’re lowering the weight back down in a controlled manner (key here is controlled-resisting gravity and not just letting the weight flop back down!), and the knee is extending.  Eccentric exercises have been shown to promote tendon remodeling and collagen fiber linking in the Achilles and patellar tendons.  These findings have been extrapolated to the proximal hamstring tendons, as well, although most research for this particular issue comes only in the form of case reports, meaning it’s not as clear-cut.  Additionally, heavy, slow resistance training with both concentric and eccentric portions has more recently been shown to have potential for proximal hamstring tendinopathy.  So, we should consider eccentrics to be a part of treatment once the tendon is able to handle less provocative loads (isometrics and concentric exercises), as they can make matters worse when introduced too early in the rehabilitation process, along with targeted exercises emphasizing gluteal and core strength and control and progressive resisted hamstring work.  

Also, why the focus on glutes and the core?  While “glute activation” seems like the PT buzz phrase of the moment, our glutes are designed to be our strongest hip extensors.  When we lose strength or the ability to get them to “turn on” at the correct times, the hamstrings try to do more work to extend the hip.  So, better glutes=less hamstring strain.  As for the pelvic and core stability, remember that the hamstring tendon attaches onto our pelvis, so we want this to be a solid base from which the hamstring can do its jobs moving the leg.  This also plays into that anterior pelvic tilt mentioned earlier-the glutes and lower abdominals work together to tilt the pelvis into a posterior pelvic tilt, so, out of that troublesome position that increases compressive forces on the hamstring tendon.   

source: Shredded Core

What about stretching the hamstring? In the past, many have been quick to blame any hamstring issues on “tight hamstrings”, and prescribe hamstring stretches. But, static stretching (as in, bending over and touching your toes) does a solid job of increasing compressive loads (there’s that term again), and in many cases, is bad for the tissue. Plus, although runners are the first to laugh at how tight their hamstrings are when I check that clinically, the truth is that running is not an activity that requires a whole ton of hamstring flexibility. With that said, it can be beneficial to work on the soft tissue to ensure that excess tension or adhesions between muscles aren’t increasing pain. Manual therapy, foam rolling, percussive devices such as Hyperice guns, cupping, and instrument-assisted techniques all have their place in improving tissue quality and altering the brain’s feedback to allow the muscle to relax. For those who truly have tight hamstrings that limit their bike positions, stretching might have a place, but only after the tendinopathy is dealt with-while trying to heal the injury, bike position should accommodate the body. Also, in some cases, again in those athletes with anterior pelvic tilts, physically shortened hip flexors and quadriceps might be found. In these circumstances, when the muscles on the front of the hip actually don’t have adequate length to allow for proper hip extension and pull the pelvis out of alignment, stretching the hip flexors and quadriceps would be indicated.

When it comes to the actual swim/bike/run (when enough healing has occurred to allow them!), several actions can be taken to help things out. Swimming hasn’t been mentioned much here, but the hamstring does play a role extending the hip while kicking, and pushing off of the wall. Pull buoys obviously unload the kick, and caution should be used on turns. Granted, my feeble lung capacity causes me to look for any excuse out of them, but flip turns in particular put the tendon into that fully hip flexed compressed position, followed by powerful hip extension, so they might not be the best. Lowering the bike seat a bit, and finding a saddle that allows one to comfortably roll forward a bit more onto the pubic bones and place more weight through the arms unloads the hamstrings and their attachments to a greater degree. Run gait tweaks to consider would be making sure that the trunk isn’t leaned too far forward (we do want some slight forward lean, but not excessive amounts), and preventing overstriding (which often comes in the form of increasing stride rate).

But even the best designed PT program doesn’t always work for this injury (tendons have low blood flow in general, and aren’t the best healers), and medical interventions can be needed, or can be a useful adjunct. Some interventions that have been used for high hamstring tendinopathy include extracorporeal shock wave therapy (ESWT), corticosteroid injections, platelet-rich plasma injections (PRP), and surgery. ESWT is non-invasive, and involves delivering shock waves to the tissue to promote healing. It has shown promise for high hamstring tendinopathy, but finding a practitioner who delivers this treatment can be difficult. Corticosteroid injections have been shown to assist in pain relief in the short-term, but they do not address the underlying degenerative changes in the tendon, and can suppress collagen synthesis-the very thing we want to happen for true tendon repair. So, they can be helpful in more acute cases, especially if an athlete has a competition approaching, but are usually not a long-term solution. PRP, which has become more common in recent years, involves spinning one’s own blood through a special centrifuge, extracting the platelet-rich plasma components, and injecting them into the tendon to try to get it to heal. Research on this treatment is mixed, as are athlete experiences. The injection itself is painful, usually takes 4-6 weeks for any results, involves rehabilitation, and can be pricey, especially since few insurance companies cover it. Still, it is a consideration for some with the injury who might not be responding to regular rehabilitation, but do not wish to consider surgery. Finally, surgery to debride and repair the tendon is done in particularly severe or stubborn, long-standing cases in which conservative treatment has failed to provide adequate return to function, when the tendon is physical damaged to a large degree (i.e. extensive partial tearing), or when the sciatic nerve has become entrapped or involved. Many do experience a return to training and competition afterwards, but any surgical procedure is a large undertaking that should be carefully thought through.

So there you have it! High hamstring tendinopathy is one of those injuries that tends to perplex and frustrate everyone who suffers from it, but if you read all of that, you’re off to a good start in terms of having the diligence and patience required to get past it. Because you’ll find plenty of horror stories, I’ll wrap this one up with some hope-I've managed to get past this injury related to overuse (and my solid anterior pelvic tilt!) twice on the left side, a decade apart, and once related to that previously mentioned traumatic fracture/bone spur on the right side. It’s taken time (6-12 months) and plenty of rehab in each circumstance, but I like to think that while some injuries are stubborn, triathletes, well, we’re pretty tenacious ourselves!

Exercise Suggestions

This is obviously not an inclusive list, just some examples! Most of these exercises are hamstring-related, but a good rehabilitation program should also include plenty of pelvic, glute, and core stabilization that is tailored towards the individual’s specific needs/weaknesses/strengths. Sets of 20-30 are a good place to start for all of these.

Phase I

Phase II

Phase III

Phase IV

References: 

  1. Beatty NR, Felix I, Hettler J, Moley PJ, Wyss JF. Rehabilitation and Prevention of Proximal
    Hamstring Tendinopathy. Current Sports Medicine Reports. 2017;16:162-171.
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    and muscle recruitment during cycling. Journal of Science and Medicine in Sport. 2008;11:8.
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  4. Chumanov ES, Heiderscheit BC, Thelen DG. Hamstring Musculotendon Dynamics during Stance and Swing Phases of High Speed Running. Medicine and Science in Sports and Exercise. 2011;43:525-532.
  5. Degen RM. Proximal Hamstring Injuries: Management of Tendinopathy and Avulsion Injuries. Current Reviews in Musculoskeletal Medicine. 2019;12:138-146.
  6. Kotler DH, Babu AN, Robidoux G. Prevention, Evaluation, and Rehabilitation of Cycling-Related Injury. Current Sports Medicine Reports. 2016;15:199-206.
  7. Schultz M. The Primary Muscles Used for Cycling and How to Train Them. Coach Blog: TrainingPeaks; 2015.