Hamstring Tendinopathy (a real pain in the butt!)
Article by the Drummond Team
We all know how annoying it can be to have an injury that reacts adversely to acute spikes in training load such as Patella tendonitis and Achilles tendonitis, so why don’t we know more about this real pain in the butt…Hamstring Tendinopathy? Before we discuss this pathology we must firstly stress self diagnosis of this injury is very difficult due to the location of the tendons (close to adductors, sciatic nerve and deep to the Gluteals) therefore if this articles rings any bells we would recommend seeing a health care practitioner such as a Physiotherapist.
What are Hamstrings and what do they do?
The hamstrings are attached to the Ischial tuberosity (see fig 1) and consist of three muscles; Biceps Femoris, Semitendinosus and Semimbranosus.
Function
During running, the hamstrings have three main functions;
- Decelerate knee extension at the end of the forward swing phase of the gait cycle.
- At foot strike, the hamstrings elongate to facilitate hip extension thus further stabilizing the leg for weight bearing.
- Assist in flexing the knee during the take-off phase.
Fig 1. Origin of Hamstring muscle group.
Who is susceptible to this injury?
This injury can be prevalent in ‘endurance runners’ as well as those who participate in more explosive sports such as sprinters or hurdlers. Due to the biomechanics involved when decelerating and changing direction those who play team sports such as football and rugby can also be prevalent. The onset of pain is mostly gradual therefore don’t expect an obvious mechanism of injury.
Risk factors (The controllables)
Inappropriate strength training (poor technique)
Below is an example of excessive hip flexion (fig 2) during a squat, which increases the pressure on the hamstring tendons as the hamstring needs to contract and lengthen and thus these repetitive movements increases the tensile and compressive load at the tendon insertion (Ischial tuberosity-fig 1).
Fig 2. Squatting with increased hip flexion.
Running Form
If you have been in to our clinic for a gait analysis, you may have heard us discuss tendons and their important role in storing elastic energy for an efficient gait. When we unknowingly alter our gait i.e run with a forward trunk lean or most commonly over stride in an attempt to increase our pace we inadvertently put increasing demands on the proximal hamstring and thus the energy storage system is susceptible to a higher load.
Other potential causes (Intrinsic Risk Factors) which will be explored in your clinical examination;
- Previous injury (Subjective assessment)
- Sciatic nerve irritation (Neurological testing)
- Malalignments (Posture assessment)
- Muscular Imbalance (Strength and Range of movement testing)
- Pelvic/lumbar and Core weakness (functional assessment)
Don’t wait….Test it yourself
As mentioned earlier this injury is best diagnosed by a Physiotherapist, however we have provided some basic loading tests to help you determine if your buttock pain could potentially be related to this pathology.
The principle of these DIY tests is to reproduce pain by loading the proximal hamstring tendons. This is done by progressively increasing the compressive and tensile load, by increasing the angle of hip flexion (injury risk factor)
- Single leg bent knee bridge (low load clinical test)
- Long lever bridge (moderate load)
- Arabesque movements to single leg deadlift (high-load clinical test).
Got the diagnosis….. Now lets start the rehab
PATIENCE!!!
The tendon’s thickness, fibrousness and poor blood supply are the causes of difficult healing, therefore patience and appropriate loading is key. A graded approach will be used from day one with an individualised plan to optimise the hamstrings capabilities whilst not aggravating the injury (a true balancing act).
Modified Activity
Your only as good as your weakest link! Aggravating sporting activities may be replaced with other forms of cardiovascular fitness, such activities can include swimming and water running.