Proximal hamstring tendinosis is one of the most frustrating injuries that affects long-distance runners. Characterized by chronic overuse of the tendon that connects the hamstring to the sit bone and pelvis, it can cause pain in the buttocks, especially when sitting, sitting on hard surfaces, driving, or running.
Runners who suffer from this injury find it particularly difficult to return to their sport because of the complexity of the recovery process and the strain the injury places on the tendons and muscles involved in running.
In this blog, we will dive into the details of proximal hamstring tendinosis, why it’s particularly troublesome for long-distance runners, and how the right treatment approach can speed up the recovery process.
What is Proximal Hamstring Tendinosis?
Proximal hamstring tendinosis is a condition that occurs when the tendon connecting the hamstring to the sit bone becomes chronically overused. This leads to pain that is typically felt in the buttocks.
For runners, it can manifest as discomfort during running, particularly with repetitive motion, and also when sitting or engaging in activities that involve prolonged periods of rest. It is important to note that this condition is different from simple hamstring strain, as it involves the tendon becoming weak and unable to handle the forces applied to it during daily activities and running.
The condition is particularly challenging to treat because the tendon is hard to rehabilitate with standard physical therapy approaches. Recovery can take anywhere from 6 to 9 months, even with appropriate care.
The reason for this prolonged recovery time lies in the unique demands placed on the tendon during running. When the hamstring tendon is under constant strain from running, especially in long-distance events, it becomes difficult to heal. Runners typically face two choices: either stop running, which most athletes are unwilling to do, or find ways to work through the injury.
Why Long-Distance Runners Are Especially Prone to This Injury
Long-distance runners are particularly vulnerable to proximal hamstring tendinosis for a few key reasons. One major factor is contralateral pelvic drop, which occurs when one side of the pelvis drops lower than the other during running. This misalignment can place extra strain on the hamstring tendon.
Additionally, runners often experience increased pelvic rotation, weak glutes, and poor eccentric hamstring control, all of which further exacerbate the condition.
The hamstring muscle group plays a vital role in controlling the movement of the pelvis, especially during running.
When the glutes are weak, the hamstrings must work harder to stabilize the pelvis, which increases the risk of injury. Over time, these compensations can lead to the breakdown of the tendon and the development of tendinosis. These factors make it particularly challenging for long-distance runners to prevent and recover from the condition.
Why Recovery is So Difficult
Recovery from proximal hamstring tendinosis can be slow, often taking anywhere from 6 to 9 months. This is because the tendon, once injured, loses its ability to handle the forces of running.
During the recovery process, the body needs to repair the tendon and restore its strength and function. However, this process is complicated by the fact that tendons are slow to heal due to their limited blood supply.
Effective recovery requires a combination of techniques to address different aspects of the injury. The first stage of recovery involves activating the hamstring and glutes, a process that typically takes around 3 weeks. This involves exercises and drills to stimulate the muscles and get them working properly again.
Next, strength training is essential to reload the hamstring and glute muscles. This phase can last between 6 and 12 weeks, and it involves heavy loading that many runners are not accustomed to but is necessary to rebuild strength in the affected area.
Stabilizing the pelvis is another crucial aspect of recovery. The pelvis must be able to maintain proper alignment and avoid issues like pelvic drop or knee valgus (when the knees cave inward). Achieving this level of control can take another 6 weeks.
Once these stages are completed, runners need to practice fast movements, including plyometric exercises, to ensure they can perform at the speed and intensity required for running. This last phase can take an additional 2 months or more. As a result, the entire recovery process can take up to 9 months.
Key Strategies for Treating Proximal Hamstring Tendinosis
Runners with proximal hamstring tendinosis often experience frustration because many traditional rehab methods do not work effectively. The key to successful rehabilitation is understanding that simply resting the tendon will not resolve the issue. In fact, rest alone can weaken the tendon further. Proper loading and targeted rehabilitation are essential to remodeling the tendon and making it stronger.
Several techniques can help speed up recovery and improve the effectiveness of rehabilitation. These include:
- Shockwave Therapy: Shockwave therapy has been shown to help stimulate the healing process in tendons, particularly those that are slow to respond to traditional rehab techniques. It helps increase circulation and stimulate the production of collagen, which is important for tendon repair.
- Deep Tissue Cross-Friction Massage: This type of massage can help break down scar tissue and improve blood flow to the affected area, aiding in the healing process.
- Real-Time Running Feedback: Runners can benefit from using real-time feedback technology to assess their running mechanics. This allows them to make adjustments to their form and ensure that they are not placing undue stress on the hamstring tendon during their runs.
- Strength Training and EMG Feedback: Strength training plays a vital role in rebuilding the hamstring and glute muscles, and using electromyography (EMG) feedback can help activate the muscles more effectively. This ensures that the glutes are properly engaged, which is essential for stabilizing the pelvis during running.
Prevention is Key
Preventing proximal hamstring tendinosis is much more effective than dealing with its aftermath. There are several preventive measures that runners can take to reduce their risk of developing this condition:
- Glute Band Work: Activating and strengthening the glutes is essential for preventing hamstring injuries. Exercises such as glute band work help improve glute activation and reduce strain on the hamstrings.
- Inner Abdominal Pressure Training: Training to stabilize the pelvis through abdominal pressure exercises can help reduce the risk of pelvic drop and other alignment issues that contribute to hamstring injuries.
- Eccentric Nordic Hamstring Curls: This exercise targets the hamstrings and is particularly effective for building eccentric strength, which is crucial for preventing injuries like tendinosis.
- Strength Training: Runners must incorporate strength training into their routines, including exercises that target the hamstrings, glutes, and core muscles. While many runners dislike going to the gym, this type of training is vital for long-term injury prevention.
Common Mistakes in Treating Proximal Hamstring Tendinosis
- Misdiagnosis as Piriformis Syndrome: Many runners mistakenly diagnose the pain as piriformis syndrome, which is not the underlying cause of their discomfort.
What is Piriformis Syndrome? It occurs when the piriformis muscle, located in the buttocks, becomes tight or spasms. This muscle is close to the sciatic nerve, and when it tightens, it can irritate or compress the nerve, leading to pain, numbness, or tingling sensations along the path of the sciatic nerve, often running down the leg.
Piriformis Syndrome is often misdiagnosed because the symptoms are similar to sciatica, which is typically caused by a herniated disc or other spinal issues. However, Piriformis Syndrome specifically involves the piriformis muscle and its effect on the sciatic nerve.
Common Symptoms of Piriformis Syndrome:
- Buttocks Pain: Deep pain in the buttock, often aggravated by sitting or prolonged standing.
- Sciatic Pain: Pain radiating down the back of the leg, following the path of the sciatic nerve.
- Pain with Movement: Pain intensifying when climbing stairs or walking uphill due to increased pressure on the piriformis muscle.
- Complete Rest Recommendation: A common recommendation is complete rest, which can be counterproductive. While rest may provide temporary relief, it does not address the root issue of tendon weakness. Once runners resume activity, they may experience even worse pain.
- Failure to Gradually Reload the Tendon: Simply resting is not enough. It’s essential to gradually reload the tendon with exercises that provide controlled stress. This helps the tendon remodel and strengthens it over time.
- Neglecting Running Mechanics: Runners should also focus on correcting key running mechanics, such as avoiding pelvic drop and controlling knee valgus. However, many athletes and rehab professionals lack the necessary technology and systems to properly assess and correct these mechanics.
Conclusion
Proximal hamstring tendinosis is a challenging injury for long-distance runners, but with the right treatment plan and approach, recovery is possible. By focusing on proper rehab techniques such as strength training, muscle activation, and real-time feedback, runners can address the root causes of the injury and make a full recovery.
Preventive measures, including strengthening the glutes, stabilizing the pelvis, and incorporating eccentric exercises, can also help reduce the risk of developing this condition in the future.
Understanding the complexities of this injury and following a comprehensive rehab plan is key to getting back to running and staying injury-free in the long term.
