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Proximal Hamstring Tendinopathy
Written by: Blake Scott, MPHTY, BA (KIN, HONS) / Registered Physiotherapist
Proximal Hamstring Tendinopathy (PHT) describes a condition in which the tendon that connects the hamstring muscles to our pelvis (ischium) become irritated, resulting in pain and limited function.
Most people will have a complaint of a well-localized deep buttock pain that can be aggravated by lunging, squatting, running (hills/sprinting), sitting, and stretching the hamstring.
Some people may also have some accompanying sciatic nerve irritation due to its anatomical proximity to the hamstring tendon.1
There are many extrinsic and intrinsic factors that can lead to the development of PHT.
· Training errors – increase volume/intensity too quickly
· Sudden introduction of new activity, Ex. sprints, lunging, hurdles, hill running
· Weakness in Glute and Adductor muscle groups leading to overloading of hamstrings
· Pelvic positioning during activity
Phase 1 Rehab
The initial phase of rehab for PHT involves offloading the irritated tendon and introducing Isometric loading exercises to build load tolerance. Any intrinsic factors should also be addressed during this phase.
- Modify sitting posture (elevated seat height, seat cushion)
- Limit aggravating activities – running, squatting, lunging
- Soft tissue work to reduce muscle tension
Build load tolerance
- Isometrics are a great way to introduce tendon loading and recent research has shown it can have an analgesic effect on tendon pain in lower limb tendinopathies 2
- We want to start with isometric loading of the hamstring tendon in positions that limit tendon compression (limit hip flexion)
Exercise 1 – Single Leg Bridge Hold
- 5 sets, 30-45 second holds @ 70% max voluntary contraction (MVC)
- Some pain is acceptable (0-3/10) during and after exercise but should settle within 24 hours
- This exercise can also be initiated with two legs if single leg loading is too irritating
Phase 2 Rehab
In phase 2 rehab we want to introduce isotonic loading with minimal hip flexion (tendon compression). The goal is to restore hamstring strength and capacity in functional range of motion.
Emphasis on phase 2 exercises should be on Heavy Slow Resistance (HSR) training. Meaning exercise should be performed at a slow, fatiguing tempo starting at 15 Repetition Max (RM) progressing to 8RM.
Exercise 1 – Single Leg Bridge
Exercise 2 – Nordic Hamstring Curl
Exercise 3 – Supine Eccentric Hamstring Curl
Phase 3 Rehab
Phase 3 rehab of PHT involves continued hamstring strengthening and functional training in greater degrees of hip flexion.
The goal of this phase is to build load tolerance in positions of tendon compression aka. Resilience to re-injury.
Exercise parameters are similar to that of Phase 2 rehab. Slow tempo loading (Heavy Slow Resistance Training) starting at 15 Repetition Max (RM) and progressing to 8RM.
Exercise 1 – Romanian Deadlift w. Kettle Bell
Exercise 2 – Single Leg Romanian Deadlift w. Kettle Bell
Phase 4 Rehab
Depending on activity demands, some individuals may require a Phase 4 rehab of Plyometric training (energy storage and release). Exercise examples include, bounding, sprinting leg curls, and sleds.
BLAKE SCOTT, MPHTY, BA (KIN, HONS)
Blake joined GRSM in July 2018. Blake graduated with his B.A. Hons – Major: Kinesiology from the University of Western Ontario and a Master of Physiotherapy from the University of Sydney. Blake’s graduating class at University of Sydney ranked 1st in the 2017 QS World University rankings for sports-related subjects including Physical Therapy, Sports Therapy and Rehabilitation. Blake has worked in hospital & multi-disciplinary clinics and has also been the team Physiotherapist for the University of Sydney Women’s Australian Rules Football Team. Blake has always been an avid sportsman growing up playing hockey, soccer, baseball, and volleyball. His dedication for sport has developed into a passion for treating sport-related injuries and promoting a healthy active lifestyle. Blake’s treatment style focuses on the implementation of exercise and manual techniques to relieve pain and improve function.He also believes that a comprehensive injury education is important in enabling his clients to take control of their injury and optimize their outcomes. In his free time Blake enjoys staying active playing recreational baseball and hockey as well as taking his dog Louie for hikes.
1- Goom T, Malliaras P, Reiman M, Purdam C. Proximal hamstring tendinopathy: clincal aspects of assessment and management. J Ortho Sports Phys Ther. 2016; 46(6): 483-93
2- Rio E, Kidgell D, Purdam C, et al. Isometric exercise induces analgesia and reduces inhibition in patellar tendinopathy. British Journal of Sports Medicine 2015;49:1277-1283.
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