The hamstring muscles are responsible for propelling you forward, but high hamstring tendinitis can hinder your stride and be a real pain in the rear.

Get together with any group of runners and it's like a convention of orthopedic surgeons. Long, complex-sounding conditions are referred to and discussed at length. Treatment options, like night splints, orthotics and various braces are compared and suggested by injury veterans who have survived common running maladies such as plantar fasciitis and sore kneecaps.

There is one injury, however, that is spoken about in whispers, often since the inflicted runner no longer makes it to the group runs or track workouts. The condition is known in the medical jargon as proximal hamstring tendinopathy or high hamstring tendinitis and refers to inflammation of the common origin of the three hamstring muscles. To the rest of us it is quite literally a pain in the … rear.

Below, a simple strengthening workout relieves a common tight spot.

Among its many functions, the hamstring complex is responsible for propelling your body forward with every step. The hamstring complex is actually composed of three separate muscles that share the same origin at the bottom of the pelvis but all attach to different areas after crossing behind the knee joint. If you were a car, your quads would be the springs and your hamstrings would be the engine. Needless to say, like the engine of a car, more miles frequently means greater chance of the engine breaking down. Despite both the potential seriousness of the injury and its prevalence among runners, it is largely ignored in the orthopedic literature, with much greater attention focused on traumatic injuries of the hamstring.

In one of the few articles that investigates high hamstring tendinopathy in a runner, Dr. Michael Fredericson notes that the basic anatomy and function of the hamstring muscle complex predisposes it to running injury. As the muscle is largely composed of "fast-twitch" Type II muscle fibers, capable of generating a high degree of tension on the tendon with every contraction, a great deal of tension is generated within the common tendon of the three muscles. Additionally, while running, the hamstring muscle contracts while in a stretched position as the leg strides out in front of the body. This forces the hamstring to begin contracting with the hamstring muscles and tendon already under significant tension from the stretch.

Functionally, the hamstring muscle complex has three basic roles with running: slowing the striding leg down as it approaches the ground; extending the hip and propulsion of the body forward; and assisting the calf muscle as it helps to move the knee.

After seeing literally thousands of patients over the past 12 years in sports physical therapy, one fact has become very apparent: high hamstring tendinitis is almost exclusively a runner's injury. In this it is unique, as "tennis elbow" is found equally in common mechanics and tennis players, and "jumper's knee," is not only suffered by basketball and volleyball players. High hamstring tendinopathy is also characterized by several other factors, some of which are critical to the initial diagnosis and subsequent management of the condition.

The predisposing factor for many runners can be a known or unidentified level of sciatic nerve irritation. This nerve irritation can be caused by lower back dysfunction, overstretching of the nerves in the leg or because of swelling in the area of the tendon. In addition to his findings described above, Fredericson observed the inclusion of nerve and lower back irritation with the presentation of hamstring dysfunction in an elite runner. The initial introduction of tendon pain is often preceded by a sometimes subtle level of low back discomfort and radiating tingling, numbness or pain in the back of the leg. This ensuing nerve irritation may weaken the hamstring muscle and leave the muscle and tendon vulnerable to injury.

Case Study

Mary, a 45-year-old runner and triathlete, has been unable to train for the New York City Marathon because of a pain in the buttock and sit bone region. She works at a computer and frequently sits for six to eight hours a day. She will sometimes feel lower back pain that includes a sharp tingling down the back of her leg. She is able to run at a very slow place but cannot complete her long runs or perform any speed work due to pain at her sit bone.

As exhibited by Mary's case, the injury is characterized by a deep pain at the site of the ischial tuberosity or "sit bone." The condition begins with soreness after running but progresses to pain with activity and often soreness with the direct pressure of sitting. In most cases the pain comes on without any acute event but rather increases over time with continued running. As the runner can often have a history of lower back pain, the symptoms frequently include a radiating pain that crosses the knee, suggestive of nerve inflammation from the lower back. After a longer period of high hamstring injury, changes in running gait are sometimes apparent as the runner begins to "ride" over the leg and not use the hamstring complex to propel the body forward.

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The three hamstring muscles (biceps femoris, semimembranosus, semitendinosus) have a common origin on the ischial tuberosity of the pelvis. This common tendon is subjected to a high degree of tension as the hamstring muscle group propels the body forward during running. This repetitive tension can lead to an overuse injury of the high hamstring tendon.

Treatment of the injury should initially address identification and treatment of any lower back involvement with a visit to an orthopedic surgeon or spine specialist. Once lower back pathology has been ruled out or treated, treatment of the high hamstring can begin. The important areas to address are strength of the hamstring, hip and leg, flexibility, and soft-tissue mobilization of the tendon and hamstring. Since running is an aggravating factor and is likely preventing the healing process from beginning, it is best to find other means of cardiovascular exercise.

Mary makes several ergonomic changes to address her lower back symptoms, including avoiding the slumped position, not sitting for longer than 15-20 minutes without a short standing break and temporarily avoiding hamstring stretching to allow the sciatic nerve to heal. Mary also begins an exercise program that emphasizes general leg strengthening and avoids direct hamstring exercise. She stops running and starts riding a stationary bike and swimming to cross train.

The purpose of the initial phase of the treatment process is focused on cross-training and general hip and leg strengthening (quad, calf, gluteal muscles, hip abductor). Special care should be taken early in the reconditioning process to avoid too much stress on the healing tendon. Direct hamstring work, as with a hamstring curl machine, can be aggravating to the tendon and should be avoided at this stage. Direct hamstring stretching should also be avoided or done cautiously to prevent overstretching an inflamed sciatic nerve or hamstring tendon.

After a reconditioning and healing period of six weeks, Mary no longer feels the same level of soreness at her high hamstring tendon. She is able to begin full weight-bearing training on the Stairmaster and elliptical trainer and adds direct hamstring strengthening exercise into her rehabilitation program. Mary also starts to stretch her hamstring and uses a foam cylinder to massage the hamstring muscle and tendon.

After this protective phase is completed, more specific hamstring work can begin, as detailed in the included exercise program. As a general criterion, once hamstring strength is nearly equal, a light running program can be initiated.

Prevention of hamstring problems mirror the later phases of the rehabilitation program. Those without any hamstring problems will benefit from maintaining or improving hamstring and leg strength and can incorporate direct hamstring work into the initial exercise program. All phases of exercises, as detailed in the exercise program, can be used. Another important factor in preventing high hamstring problems is avoiding excessive stress to the lower back. As in the case of Mary, being mindful of sitting ergonomics can help with those who sit for long periods of the day. The important factors are avoiding the slumped position when sitting and taking frequent sitting breaks.

The process of returning to running after an extended period of high hamstring injury can be a long one but can be done successfully with a patient and thorough reconditioning program. As with any injury, early intervention is the key to minimizing time away from running. Many studies have shown the importance of resistance training for endurance athletes, especially as they age.

Exercises

These exercises are not meant to take the place of either an evaluation by a physician or a guided treatment program by a physical therapist. If any difficulties are experienced with the program, seek the guidance of a sports medicine professional.

Level 1 Exercises

This initial level of exercise is focused on general hip and leg strength without specifically isolating the hamstring muscles. Cycling or swimming should be used for cardiovascular training. At this point, running should be stopped so that the hamstring tendon can begin to heal.

Flat Bridge (Glute muscles)

Tighten abs, lift hips off of floor and tighten glute muscles. Hold position, taking care not to lift too high and arch lower back. Hold for 30 seconds, then try 15 repetitions, lifting hips up and down as pictured below. Continue holds and repetitions until glutes are fully fatigued and are burning. 3-4 sets Can be performed with one leg for extra difficulty.



Leg Press (quadriceps)

Using 30-40 pounds, position foot and lower leg so that knee and foot are at the same height as pictured below. Keeping weight on heel of foot, press out and hold position Hold for 30 seconds, then try 15 small repetitions. Continue holds and repetitions until quad is fatigued and is burning. Do 3-4 sets with a short break between each.



Side-lying Hip (Hip abductors)

10-15 repetitions in each of the below positions without stopping in between. Fatigue/burn should be felt in outside of hip. 3-4 sets.

Foam Roll Hamstring Massage

Use foam roller to massage hamstring and tendon for 5-10 minutes.

Level 2 Exercises

This second level of exercise should be started when the hamstring tendon area becomes less sore to direct pressure and when the previous level of exercises can be performed without any significant discomfort. Cardiovascular training can be moved to the Stairmaster or elliptical.

Hamstring Bridge (Hamstring muscles)

Tighten abs, lift hips off of floor and tighten hamstring muscles by trying to pull heels toward hips. Hold position, taking care not to lift too high and arch lower back. Hold for 30 seconds, then try 15 repetitions, lifting hips up and down as pictured below. Continue holds and repetitions until hamstring muscles are fully fatigued and are burning. 3-4 sets. Can be performed with one leg for extra difficulty.



Squat (quads, glutes, hamstring)

Squat down while reaching hips back. Weight should be on heels. Hold position slightly above 90 degrees for 20-30 seconds, then move up and down for 10 repetitions. 3-4 sets



Hamstring Stretch

Lie on back with stretching leg slightly bent at the knee. Point foot Bring leg back until a stretch is felt in the hamstrings, hold for 30 seconds. Stretch should not be felt in calf or foot.



Level 3 Exercises



This final level of exercise can begin when the hamstring-specific exercises of Level 2 do not elicit any soreness at the high hamstring area. Two to four weeks of the direct hamstring strengthening exercises of Level 2 should be finished before moving to Level 3.

Hamstring Curl (Hamstrings)

Select a lighter weight so that a higher number of repetitions can be performed. Bar should be set at the end of the lower leg. 3-4 sets of 15



Treadmill Pull (Hamstring, glutes)

Stand on the side of treadmill with the involved leg on the belt and the treadmill off. Keep opposite hip against side rail. Keeping foot flat and knee fully extended, pull belt backwards until heel begins to lift off of belt. 3-4 sets of 10-15. Additional resistance can be provided by having someone rest one foot on belt for extra friction.

Hamstring Squat (Hamstrings, quads, glutes)

Squat down while reaching hips back, back should be parallel to floor. Weight should be on heels. Hold position slightly above 90 degrees for 20-30 seconds, then move up and down for 10 repetitions. 3-4 sets.



General Program Guidelines

Exercises should be performed three to four days a week, with at least one day of rest in between.

After advancing to the next level of exercise, continue to do the previous levels

The goal of each exercise is to reach muscular fatigue and burn. After performing the exercises several times they should begin to get easier. In order to keep them challenging, add time and repetitions to each set as necessary.

Each exercise should be done to at least a moderate level of fatigue/burn and should be felt in the indicated muscle. It is common for an injured leg to fatigue/burn less than the uninjured leg, despite the fact that it is usually much weaker. After each exercise, fatigue should be experienced equally in both legs. Care should be taken to focus on using both legs evenly to ensure that the injured leg's muscles can be strengthened.

For those with the goal of establishing a program for injury prevention, perform Level 1 and 2 exercises for one to two weeks apiece before starting Level 3 exercises.

Ian McMahan is head athletic trainer at Active Care Physical Therapy in San Francisco and has worked with runners and endurance athletes of all ages and ability levels. He has a master's degree in exercise physiology from the University of Maryland. Since having to walk half of his first 5K in college, he has run five marathons, including two Boston Marathons.

Lisa Giannone is the founder of Active Care Physical Therapy in San Francisco and has worked with professional and elite athletes from all over the U.S. She is responsible for developing the exercise theory and technique of many of the exercises in the hamstring program.

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