Proximal hamstring tendinopathy is quite literally a pain in the butt, and it should remain that way throughout the rehabilitation process. Possibly the most important aspect of hamstring rehabilitation is to ensure it remains progressive, and in the case of hamstring tendinopathy, mildly irritating. Ideally patients will be experiencing morning stiffness with pain of about 1 or 2/10. It is important to note that this does not mean limping, if you prescribe exercises which cause people to start their day limping, they will stop doing them pretty quickly, and then nobody wins.
I will give a brief overview of the role of tendons and the associated risk factors, however if you would like to jump to the exercises, then scroll on down.
To give an understanding on how to best progress exercises for hamstring tendinopathy, we will briefly have a look at the role of tendons so we can understand how they become susceptible to injuries. Tendons simply attach muscles to bones, causing the bones to move when the muscles contract. Tendons are obviously built to withstand high amounts of load, but can still be injured from too much tension (tensile load), or from rubbing/compressing on bony structures (compressive load). For a great video demonstrating the difference between compressive and tensile load, check out the ‘tendon compression and pain’ video in our recommended viewing section here.
Common Signs of Proximal Hamstring Tendinopathy
- Pain on sitting, which is made worse with a harder surface such as a hard plastic chair or wooden stool
- Finger point identification. It can also be a more general area around the ischial tuberosity, but most often a very specific point of irritation
- Increase in pain with tendon compression such as leaning forwards to walk or run uphill, causing the hamstring tendon tocompress or rub against the ischialtubersoity
- Referred posterior leg pain or parasthesia as the sciatic nerve travels in close proximity to the ischial tuberosity. This is one reason why hamstring tendinopathy can be overlooked in favour of lumbar or disc issues.
- Increase in load. There is almost always an incident such as adding sprints or interval training, running hills, heavy compressive strengthening (deadlifts), plyometric exercises, a vigorous stretching session or simply increasing training volume by >10-15%.
- Pre-season. Tendons are only as strong as they need to be, so when people enjoy a couple of months off at the end of the season, then jump into some serious conditioning work to boost their strength and fitness, it is understandable that tendons become upset.
- Muscle imbalance between hamstrings and lower glut max leads to overuse of hamstrings, resulting in hamstring dominance. This can be made worse with shortened hamstrings.
- Poor pelvic stability (poor function and control = increased quads and hamstring activation when standing on 1 leg)
- Prior knee injuries. Common among the older population who have had a knee replacement and tend to avoid bending their knees and instead choose to bend from the hips, increasing the compressive load on their hamstrings.
- Prior back injuries. People with a history of back pain tend to be poor at using their gluts, placing extra pressure on their hamstrings.
- Old age (sadly in the hamstring world this means >23 years old…..enough said)
This is not an exhaustive list, but does give us a great starting point to work with. Address the patients load, reduce irritating factors, increase glut and core strength, re-educate quality movement patterns, and gradually build their tendon strength. When done properly, this is a lengthy process with a typical rehabilitation program lasting 12 weeks or more.
Just a little side note about runners, however it can be applied to all populations. As this is an injury commonly seen in runners I believe it is worth discussing managing their load during the rehab process. It is often an especially big week of hills or sprints that started the hamstring irritation in the first place, so it will most likely be necessary for them to take a break from these activities, but they may be able to continue training on the flat. If they have been ignoring the symptoms for a long period of time and pushing through the pain, then they may have a very grumpy tendon that needs total rest from running and would prefer to be thrown in the pool for some good old deep water running. Basically the same key principles apply, the tendon will dictate their abilities; activities that illicit pain >3/10 should be avoided.The Exercises
Of course it is not possible to be prescriptive with an exercise recipe. The main goals are to reduce pain and increase function by increasing the ability of the musculotendinous unit to manage load. Everyone will present with different pain levels and varying degrees of function and must be managed accordingly. For this reason it is not possible to follow a series of exercises and expect good results. Some patients can be progressed quickly, while others will need more time to adapt. All of the exercises I will present can be performed in the home environment, however I will add in a couple of supplementary gym based exercises where appropriate. All sets and reps will be guidelines and should be modified accordingly to suit the individual.
Initially it is necessary to determine where on the pain/function spectrum the patient is. To do this I start with a single leg supine hamstring bridge. By starting with the injured leg nearly straight you will be heavily loading up the hamstring with minimal compressive load on the tendon. If this is too sore, you simply move the foot in towards the body, increasing gluteal assistance and reducing load on the hamstring tendon. Once you have found the position the patient can tolerate, then that can be their first exercise, progressing from 2 sets of 10 reps 10 second isometric holds to 3 sets of 3 reps of 30 second holds.
The catch with bringing the leg closer to the body is it increases hip flexion, leading to increased compressive load. This will mean that not everyone can tolerate this as an exercise initially. For this group of people, I start them off with prone isometric resistance band holds until their pain reduces and they are ready for hamstring bridging.
Isometric exercise progression
|1||5||5||3 x Daily|
|2||10||10||2 x Daily|
|2||5||30||2 x Daily|
Isometrics are a safe starting point and the exercises are accessible, however if you are not going to be challenging the tendon (mild pain and discomfort), then you must move on.
Nordics. Good old Nordics. These exercises seem to come in and out of fashion biannually, possibly because they appear so simple that there must be a better, more complicated (more functional) way. Personally I am happy with their ease of application, progression, and technical cueing (hold the position for as long as you can until you fall on your face). The only limitations I have heard that warrant consideration are that they work at short muscle lengths and bias more semitendinosis and less lateral hamstrings (biceps femoris). The later point is particularly important for runners as biceps femoris has been shown to have greater lengthening and EMG activity during the late swing phase of running, potentially increasing its risk of injury (Lorenz et al 2011). It is simply worth noting that the rehab does not start and finish with the Nordic hamstring exercise and it may be worth progressing people through exercises with more of a focus on tension at long muscle lengths
The Nordic exercise when introduced too early will likely result in significant discomfort for the patient, so to help them to ease into it, I start them off with isometric Nordic for their first few rehab sessions. To do this they simply find a point of forward lean they can hold for 15-30 secs and perform 2 sets of 5 reps. Again, once the discomfort drops below a 1-2/10, they can progress to full eccentric Nordics. Mjolsnes et al (2003) developed a progressive Nordic hamstring program, which provides a great guideline (not a recipe), but is especially helpful for anyone looking to implement some preseason injury prevention. See the table below.
Week Sessions Sets Reps
Once they are up to 3 sets of 10 slow and controlled Nordics, then you may want to fill in the gaps that the Nordics left out, or simply begin to add in a couple of extra exercises during the Nordic phase. There are many ways to target end range hamstrings with eccentrics, it really depends on your imagination. Depending on available equipment, I tend to use the supine fit ball hamstring bridge or supine hamstring slides. You can start both exercises with both legs, progressing to single leg as confidence increases.
I tend to progress people quite slowly through the eccentric stage, focusing on reaching higher loads to facilitate optimal tendon and muscle strength adaptation. Following the eccentric phase, it is often possible to progress quite quickly, which the athlete loves of course. Once the patient can tolerate these exercises, it is time to progress towards more functional movements. For the general public it is a great time to get them performing those exercises that would previously have aggravated such as squats and start to focus more on movement re-education to prevent a recurrence.
For the athletes, it is also a great time to introduce squats (always squats) as well as some more challenging and sport specific exercises. As speed is often a factor, then it will be necessary to train speed under load (always load) initially. This can be achieved with resistance band running, sled pushes, treadmill starts, partner assisted resisted… again, there is plenty out there depending on the athletes goals and current level of function. One of my favourite exercises for runners is the single leg eccentric running man,check it out in the video below:
Considering the tendon healing process is often a lengthy one, you do not want to throw people into burpees and head-high box jumps. It is possible to bridge the gap between strength and plyometrics with some straight forward exercises such as lunge drops and sled pushes. Of course the latter depends on available equipment, but lunge drops are particularly effective at determining whether the individual is at a suitable stage to be progressed as the high amount of compressive load involved will certainly test the integrity of the tendon:
As the goal is to continue to progress the strength of the musculotendinous unit, it is still necessary to maintain a progressive program, gradually increasing the tolerance of the tendon over time. This can be achieved by starting with a modest number of reps and sets and increasing as tolerated. As far as specific exercises go, I favour the reverse box jump, which Padulo et al (2013) found stresses elastic tissue more than muscle tissue compared to squat jumps.
Tendinopathy rehabilitation is often prolonged and hamstring tendinopathy is one of the slowest to resolve. Once you progress through your rehabilitation program, you may be functioning at a high level, but will likely still be experiencing sitting pain. It is common to still be experiencing sitting pain 12 months after commencing your rehab program.
There are plenty of hamstring videos in the resources section of the Health Sense Group website found here.
- Must be progressive
- Retrain the chain (gluts gluts gluts!)
- Use pain and discomfort to monitor progression
- Build up to higher loads as pain allows
- Keep it tailored to the individual and their chosen activity
- There is no quick fix, progressing too quickly will result in set backs
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