This is an update on an article originally written in May 2014

Running downhill?  Sprints?  New to interval training?  Got a pain in your backside?

Is it pretty much ‘on the spot’, and in one place? Does it hurt when you get out of bed?  Does it hurt when you stretch? Does the pain get better after a while?  Is it painful to drive?   It might be high (proximal) hamstring tendinopathy.

What is high / proximal hamstring tendinopathy?

There are three hamstring muscles, and they all attach in the same place: at the ischial tuberosity (the base of your sitting bones).

Proximal hamstring tendinopathy is like an overuse syndrome of the hamstring tendon, and the pain of proximal hamstring tendinopathy is swelling at the point where the tendon attaches to the bone.

The ’cause’ is often a lack of balance between the load placed upon the tendon and the tendon’s capacity to manage that load, and a mismatch is often created when people jump back into training after a break, suddenly increase the frequency or intensity of training, have a forward leaning gait when running, or have started doing hill sprints.

What can I do about it?

You first need a proper diagnosis from a clinician like myself.  Gluteal pain can have many causes and we want to be sure we are addressing the correct source of the pain.

You’ll be given some load testing to check the tendon in different levels of strain, and then I can advise a course of action to get you back to action!

Generally speaking, work will not happen directly on the tendon – we don’t want to irritate it.  Work around the area can be done to help minimize contributing factors.  The main contributor to this problem, however, is overload and less than ideal gait in running or both.

The first part of rehab advice is this:

  • No stretching (yes that’s right!)
  • Avoid prolonged sitting
  • Relative Rest
  • Isometrics for the pain

Isometric exercise with minimal hip flexion will be the start, and this should help reduce your pain making sitting, bending, driving and walking easier.

We will then move into helping the tendon learn to increase its load capacity so that it can gradually withstand the strain you want to put through it.  This will happen through a series of 3 progressive loading exercise sets.  You’ll get re-tested at intervals to check how the tendon is coping with its demands and to determine if it’s ready to take the next progression.

What if it hurts to do the exercise?

Don’t be afraid of a little discomfort – it’s normal! Anything on a zero (no pain) to 10 (most pain ever) scale within the range of 0 to 3 is safe to experience during or up to 48 hours afterward. For some 4-5 is acceptable though we’d watch that more carefully.  If you’re at those levels during or within 48 hours, it’s generally safe to continue or to progress.  If you are feeling anything over a 5 out of 10, that is a sign that for some reason the progression is too much, too soon. We can discuss how to back up and keep you moving forward in your rehab without stopping activity.

What about my return to running?

First of all, the same pain threshold guidance applies. There are two areas to focus on when returning to running training:

First we look at running gait, and second we look at training factors.

It is advisable to work with a running coach or have an experienced clinician watch you running.  Why?

Small changes in your running gait can reduce strain on your proximal hamstring tendon.  Three main changes can be made, in order (not all at once, and you may not need them all) – one is a change in cadence in order to shorten your stride, the second is running ‘taller’ and the last is changing your pelvic tilt slightly.  An experienced coach or therapist can watch you and give you cues to help guide your running re-training.

Lastly, getting back to sport progressions involve looking at three factors: volume of training, frequency of training and intensity of training.  Changing volume is easier than changing frequency which is easier than training intensity.  So extend your runs or training sessions before you increase the numbers of times you train per week.  And then up your intensity as a last progression factor.  Make hills sprints the last thing you add back to your training routine (if you did those!) as this places the highest load on the tendon.

Always see a qualified professional for diagnosis and support in your recovery.

Adapted and updated from original post on 14th May 2014