This is a question that I get not only from runners but some of the yogis that come to see me. As an active member of the yoga community and as a long-time practitioner, I see a lot of yogis. More specifically I see a lot of ashtangi yogis. Hamstring injuries are very common in this population, especially as a beginner. Proximal hamstring tendinopathy comes from chronic overstretching and overloading the proximal tendon of the hamstring complex. It can be a real pain in the butt!
What is proximal hamstring tendinopathy?
Before delving into the hamstrings, let’s review tendons. A tendon is the connective tissue that attaches the muscle to the bone. The area where the tendon connects to the bone is more susceptible to irritation and injury because of it’s limited blood supply.
Tendinopathy is a term used to encompass any issue with the tendon. This is includes tendonitis and tendinosis. There is a difference between tendonitis and tendinosis. Many of the conditions that were previously thought to be tendonitis are actually tendinosis. However because we do not necessarily know if the tendon has tendonitis or tendinosis, we refer to the condition as tendinopathy.
Tendons can get inflamed with a force that is too strong or quick. This tensile force on the tendon can cause micro-tears in the tendons. This is tendonitis. It is postulated that untreated tendonitis can become tendinosis. Tendonitis is an inflammatory condition and will respond to anti-inflammatory medication. It typically has a recovery period of 1-6 weeks.
Tendinosos is a degeneration of the tendon’s collagen proteins. This is hypothesized to occur after a period of untreated tendonitis. Collagen provides the tendon with durability and strength. Tendinosis is caused by chronic overload of the tendon without sufficient time to rest and heal. It does not have signs of acute inflammation and is not improved with anti-inflammatory medication such as ibuprofen. Early stage tendinosis can heal within 6 to 10 weeks but chronic stage can take 3 to 6 months. Tendinosis is probably more common than tendonitis but the term tendonitis is often used to encompass both.
Back to the hamstrings
The hamstrings are the group of muscles on the back of the thigh. This group is made up of 3 muscles which include the semitendinosus, semimembranosus, and biceps femoris. All 3 of these muscles attach to the ischial tuberosity (the sit bone) and then travel down the thigh and attach below the knee. The biceps femoris is the hamstring muscle that is on the outside of the back of the thigh and attaches to the fibular head (the top of the smaller lower leg bone). The semimembranosus is the hamstring muscle that is on the inside of the back of the thigh. It attaches to the upper inner part of the tibia (shin bone). In between the biceps femoris and the semimembranosus is the semitendinosus. This muscle attaches onto an area called the pes anserine that is on the front and inner part of the upper shin bone. Together these muscles work together to extend the hip (move it behind the body) and bend the knee.
Proximal is a medical term that indicates closer to the top of the the body. The proximal hamstring tendon attachment is the one at the ischial tuberosity (the sit bone). This is the most common place to get hamstring tendinopathy. It literally is a pain in the butt.
Who gets proximal hamstring tendinopathy?
Proximal hamstring tendinopathy is commonly seen in athletes. More specifically, it is seen in long distance runners and in athletes that participate in sports that require sprinting and quick changes in direction. This is because the hamstrings are active and play a large role in running and walking.
In my own practice, I see a different population of proximal hamstring tendinopathy sufferers and this is from the yoga community. The area that I live has a group of active Ashtanga yogis. Because I am a yogi myself and use to practice Ashtanga, I see many of these yogis when they are injured. Ashtanga yoga, especially primary series, requires a lot of hamstring stretching and eccentric contractions. An eccentric contraction is when a muscle is contracting while in a stretched position. This results in hamstring soreness and tendinopathy for those whose hamstrings are not strong or flexible enough.
Is hamstring tendinopathy the same as a strain?
The simple answer to this question is no. A strain is an injury that occurs suddenly when the fibers of the tendon or muscle overstretch and tear. Tendinopathy develops gradually with overuse of the muscle.
What are the symptoms of hamstring tendinopathy?
There are many symptoms of hamstring tendinopathy. These include:
- Pain at the ischial tuberosity (sit bone) and pain in the back of the thigh
- Pain decreases after a few minutes of activity/sport but is worse afterwards
- Pain with long periods of sitting
- Pain with repetitive activities like biking and running
- Pain with deep hip flexion like squatting or lunging
- Stiffness in the morning or after a period of rest
Are there risk factors for hamstring tendinopathy?
There risk factors for developing hamstring tendinopathy. These include:
- Increased age – As you age, your muscle fiber size decreases which increases the risk of muscle/tendon injuries.
- Overweight
- Weakness in core
- Weakness in hamstrings and quadriceps
- Tight hamstrings
- Previous injury at the hamstrings, knee, or groin
- Overtraining
- Poor form while training
- Fatigue during training
- Insufficient warm up
Who should I see to treat a hamstring tendinopathy?
- Physical therapist – Conservative care is the primary treatment for proximal hamstring tendinopathy. A physical therapist can help decrease pain and swelling at the area with soft tissue mobilization, dry needling, and manual therapy techniques. Strengthening slowly by progressively loading the tendon is needed in order to safely return to activity or sport. Your PT will be able to create a gradual tendon strengthening program.
- Orthopedist – If the hamstring is not responding to physical therapy or the pain is still present, then an orthopedist would be needed. There are other treatments, including steroid or PRP injections, that could help decrease the pain in the tendon. Imaging might also be needed to rule out other diagnosis and to get a better look at the tendon.
What can I do?
- Relative rest – It is essential to rest the area to decrease further pain and damage from occurring and to allow healing to begin. Swimming or water running are good alternate activities that would decrease the load on the tendon and allow it to heal. Biking is a possibility as a relative rest activity if sitting on the bike does not irritate the hamstring tendon. Light jogging or running might also be permitted while allowing the tendon the heal. This would assume that minimal pain is produced while running/jogging and that the pain goes away within 24 hours.
- Ice – Ice can help decrease the pain and swelling at the hamstring. Ice the painful area for 15 to 20 minutes at a time. I would recommend using an ice pack several times per day if the pain is constant or there is still swelling present. Ice immediately after activity.
- Strengthening – It is important to begin with gentle strengthening of the hamstrings and then progress to more aggressive tendon loading and sport-specific exercises. It is also important to strengthen the core muscles, as well as, the other muscles in the hip and thigh. See the videos below.
In review
- Proximal hamstring tendinopathy is an irritation of the hamstring attachment at the ischial turberosity (sit bone).
- It occurs from chronic overloading of the tendon.
- It typically occurs with runners or other sports that require sprinting with quick changes in direction. It can also occur with other activities such as yoga.
- Symptoms include pain at the ischial tuberosity and in the back of the thigh that decreases after a few minutes of activity but increases after the activity.
- Symptoms come on gradually.
- Weak muscles and training errors are risk factors.
- Physical therapy is the gold standard in treatment.
- There are things that you can do to help decrease your pain.
- Relative rest
- Ice
- Strengthening exercises
As always, If you have questions about the content of this post or any other musculoskeletal questions, please e-mail me.
Additional resources
https://www.physio-pedia.com/Proximal_Hamstring_Tendinopathy