Proximal hamstring tendinopathy (PHT) frequently occurs in runners who have increased their training load, particularly when this involves an increase in hill running and undertaking prolonged speed work.
What are the symptoms of PHT?
- Deep pain over the sitting bone in the buttock
- Occasional referral of pain down the back of the leg
- Pain is worse in the morning upon waking and improves as the day progresses
- Pain is aggravated with sitting, running, lunging and squatting
What causes PHT?
The hamstring is made up of three muscles at the back of the thigh that insert into the ischial tuberosity (sitting bone) in the pelvis. PHT is an overuse condition, where increasing the training volume (how much), intensity (how hard) and frequency (how often) too fast can lead to the capacity of the tendon being exceeded, resulting in inflammation and pain. In particular, PHT frequently occurs when the combination of compressive and tensile load is too much for the tendon to handle. The hamstring tendon is vulnerable to increased compression against the ischial tuberosity when the hip is flexed, which occurs during hill running and speed work. The junction between the tendon and bone is fibrous and has a poor blood supply, which contributes to PHT onset and its poor healing time.
How is PHT treated?
The first goal of rehab is to reduce pain through activity modification, by avoiding any aggravating activity. This will reduce the stress on the hamstring to a level that the tendon can manage, allowing the pain to settle. The aim should be to reduce compression on the tendon through limiting sitting, avoiding stretching and stopping running.
The next goal of rehab is to improve the tendon’s ability to handle load, by starting an exercise program that will progressively load the muscle-tendon unit (Cook et al. 2018). Addressing biomechanical factors that may have contributed to increased load on the tendon may also be required. Recovery is normally slow and may require 12 weeks of progressive loading, followed by a graded return to running.
PHT can sometimes be confused with other pathologies, such as referred pain from your back (sciatica), a deep gluteal muscle tear and an ischial ramus stress fracture. It’s important to have the correct diagnosis, so the correct treatment and rehabilitation can be implemented.