Get together with any group of runners and it’s like a convention of orthopedic surgeons. Long, complex-sounding conditions are referred to and discussed at length. Treatment options, like orthotics and various braces are compared and suggested by injury veterans who have survived common running maladies such as plantar fasciitis and sore kneecaps.
There is one injury, however, that is spoken about in whispers, often since the inflicted runner no longer makes it to the group runs or track workouts. The condition is known in the medical jargon as proximal hamstring tendinopathy—or high hamstring tendonitis—and refers to inflammation of the common origin of the three hamstring muscles. To the rest of us it is quite literally a pain in the… rear.
What the Hamstring Does
Among its many functions, the hamstring is responsible for propelling your body forward with every step. The hamstring is actually composed of three separate muscles that share the same origin at the bottom of the pelvis but all attach to different areas after crossing behind the knee joint. If you were a car, your quads would be the springs and your hamstrings would be the engine. Needless to say, like the engine of a car, more miles frequently means greater chance of the engine breaking down. Despite both the potential seriousness of the injury and its prevalence among runners, it is largely ignored in the orthopedic literature, with much greater attention focused on traumatic injuries of the hamstring.
In one of the few articles that investigates high hamstring tendinopathy in a runner, Dr. Michael Fredericson notes that the basic anatomy and function of the hamstring muscle complex predisposes it to running injury. As the muscle is largely composed of “fast-twitch” muscle fibers, capable of generating a high degree of tension on the tendon with every contraction, a great deal of tension is generated within the common tendon of the three muscles. Additionally, while running, the hamstring muscle contracts while in a stretched position as the leg strides out in front of the body. This forces the hamstring to begin contracting with the hamstring muscles and tendon already under significant tension from the stretch.
Functionally, the hamstring has three basic roles with running: slowing the striding leg down as it approaches the ground; extending the hip and propulsion of the body forward; and assisting the calf muscle as it helps to move the knee.
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How It Affects Runners
After seeing literally thousands of patients over the past 12 years in sports physical therapy, one fact has become very apparent: high hamstring tendonitis is almost exclusively a runner’s injury. In this it is unique, as “tennis elbow” is found equally in common mechanics and tennis players, and “jumper’s knee,” is not only suffered by basketball and volleyball players. High hamstring tendinopathy is also characterized by several other factors, some of which are critical to the initial diagnosis and subsequent management of the condition.
The predisposing factor for many runners can be a known or unidentified level of sciatic nerve irritation. This nerve irritation can be caused by lower back dysfunction, overstretching of the nerves in the leg, or because of swelling in the area of the tendon.
In addition to his findings described above, Fredericson observed the inclusion of nerve and lower back irritation with the presentation of hamstring dysfunction in an elite runner. The initial introduction of tendon pain is often preceded by a sometimes subtle level of low back discomfort and radiating tingling, numbness or pain in the back of the leg. This ensuing nerve irritation may weaken the hamstring muscle and leave the muscle and tendon vulnerable to injury.
A Case Study of Hamstring Tendonitis
Mary, at the time a 45-year-old runner and triathlete, has been unable to train for the New York City Marathon because of a pain in the butt and sit bone region. She works at a computer and frequently sits for six to eight hours a day. She will sometimes feel lower back pain that includes a sharp tingling down the back of her leg. She is able to run at a very slow place but cannot complete her long runs or perform any speedwork due to pain at her sit bone.
As exhibited by Mary’s case, the injury is characterized by a deep pain at the site of the ischial tuberosity or “sit bone.” The condition begins with soreness after running but progresses to pain with activity and often soreness with the direct pressure of sitting. In most cases the pain comes on without any acute event but rather increases over time with continued running. As the runner can often have a history of lower back pain, the symptoms frequently include a radiating pain that crosses the knee, suggestive of nerve inflammation from the lower back.
After a longer period of high hamstring injury, changes in running gait are sometimes apparent as the runner begins to “ride” over the leg and not use the hamstring complex to propel the body forward.
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How to Treat Hamstring Tendonitis
Treatment of the injury should initially address identification and treatment of any lower back involvement with a visit to an orthopedic surgeon or spine specialist. Once lower back pathology has been ruled out or treated, treatment of the high hamstring can begin. The important areas to address are strength of the hamstring, hip, and leg, flexibility, and soft-tissue mobilization of the tendon and hamstring. Since running is an aggravating factor and is likely preventing the healing process from beginning, it is best to find other means of cardiovascular exercise.
You can make several ergonomic changes to address lower back symptoms, including avoiding the slumped position, not sitting for longer than 15-20 minutes without a short standing break, and temporarily avoiding hamstring stretching to allow the sciatic nerve to heal. You should also begin an exercise program that emphasizes general leg strengthening and avoids direct hamstring exercise.
After a period of getting your hamstring back in working order (up to six weeks), more specific hamstring work can begin, as detailed in the included exercises below. Once hamstring strength is nearly equal, a light running program can be initiated.
How to Prevent Hamstring Tendonitis
Prevention of hamstring problems mirror the later phases of the rehabilitation program. Those without any hamstring problems will benefit from maintaining or improving hamstring and leg strength and can incorporate direct hamstring work into the initial exercise program.
All phases of exercises, as detailed in the exercise program, can be used. Another important factor in preventing high hamstring problems is avoiding excessive stress to the lower back.
The process of returning to running after an extended period of high hamstring injury can be a long one, but can be done successfully with a patient and thorough reconditioning program. As with any injury, early intervention is the key to minimizing time away from running.
The following exercises, stretches, and massages are all moves to incorporate into your routine and keep your hamstrings strong, but keep in mind that they are not meant to take the place of either an evaluation by a physician or a guided treatment program by a physical therapist. Moves should be performed three to four days a week, with at least one day of rest in between.
Lie faceup, knees bent, and feet planted on the floor. Drive through heels, contracting the glutes to send hips up toward the ceiling. Your body should form a straight line from shoulders to knees. Lower back down slowly, then repeat for 10-15 reps.
Bulgarian Split Squat
Stand in front of a low bench or step with both feet underneath your body. Place your left toes on the bench so your foot is elevated two to four inches off the ground. Hop your front foot forward (proper distance may take some trial and error) until your right foot is directly below your knee when you lower down into a full squat. That’s one rep. Perform 10 to 12 reps per side, then rest for 15 seconds and continue to the next move.
Engage your core and your glutes and lower down with control. Most of your weight should be in your front leg with the back primarily used for balance. Stop when your back knee hovers just off the ground, or when you are as low as you feel comfortable. Drive through your front foot and squeeze your glutes as you stand back up, tall and centered over your front leg.
Leg Curl With Exercise Ball
Lie faceup with your heels on top of an exercise ball. Lift your pelvis so that your body forms a straight line from head to knees, exhale, and then use your heels to roll the ball toward your glutes. Reverse the movement to roll ball back out and lower hips. Do 3-4 sets of 8 to 10 reps.
Start standing with feet hip-width apart and holding a pair of dumbbells. Send hips back to hinge at hips and lower the weights down in front of your legs. Lower the weight as far as your flexibility allows. Keep back flat and neck neutral, then push hips forward to bring weights back up. Do 3 sets of 8 to 10 reps.
Start standing with feet just wider than hip-width apart, toes pointed slightly out, clasp hands at chest for balance. Initiate the movement by sending the hips back. Bend knees to lower down as far as possible with chest lifted in a controlled movement. Keep lower back neutral. Press through heels to stand back up to starting position. Repeat for 3-4 sets of 10 reps.
Stretch your hamstrings by lying on your back, extending one leg straight up in the air, and gently drawing your toes toward your forehead.
Sit on the floor and place the roller under your thighs. Use your hands to lift your hips then roll from the knees to the glutes. To increase the pressure, cross right leg over left and roll one leg at time, turning left leg in and out. Repeat on right leg.
Ian McMahan is head athletic trainer at Active Care Physical Therapy in San Francisco and has worked with runners and endurance athletes of all ages and ability levels. He has a master’s degree in exercise physiology from the University of Maryland. Since having to walk half of his first 5K in college, he has run several marathons, including the Boston Marathon.
Lisa Giannone is the founder of Active Care Physical Therapy in San Francisco and has worked with professional and elite athletes from all over the U.S. She is responsible for developing the exercise theory and technique of many of the exercises in the hamstring program.
*** This story was originally written in 2012 and has been updated.