Hamstring tendinopathy (HT) is an overuse injury that can affect both recreational and elite athletes. The injury is located at the transition between the thigh and the buttock and can be difficult to get rid of.
The injury occurs at the attachment between the hamstring muscles and the sitting bone on the back of the thigh, up towards the buttock. Typical of this condition is pain that gets worse with running, especially after long distances, sudden accelerations or training with a lot of hills. HT often develops gradually, but can also occur acutely with injury to the tendon attachment.
Although HT is common among runners, it also affects those who play sports such as football, rugby and other activities with rapid changes of direction. In addition, non-athletes, particularly those who sit a lot, can also develop this condition.
Symptoms and diagnosis
The most characteristic symptom of HT is deep pain in the buttock, especially around the sitting bone. The pain can get worse with activities that require a lot of hip flexion, such as running, squats, lunges or sitting for long periods. Many people also experience stiffness after activity, while the pain often “eases off” after warming up, only to return after the training session or if you run for a long time.
The diagnosis can be demanding to make because pain in the buttock can also be caused by other conditions, such as referred pain from, for example, the back, pelvis, hip impingement or bursitis.
It is therefore important to have a thorough clinical assessment, which includes specific tests to load the tendon attachment of the hamstrings. These can include exercises such as a single-leg hip bridge on a bench, to see what happens when stretch and load are placed on the tendon. In many cases an MRI scan will be necessary to confirm the diagnosis and rule out other conditions.
Causes of hamstring tendinopathy
HT is most often due to a combination of external and internal factors. Common external causes include load management, such as a rapid increase in training volume or intensity, as well as activities such as sprinting, hill intervals or deep lunges that load the tendon attachment of the hamstrings.
Static stretching with a large amount of hip flexion, as in yoga, can also contribute to the development of HT. Internal factors can be weaknesses in the hip and buttock muscles, such as gluteus maximus, or genetic and hormonal predispositions that affect tendon tolerance. It is often seen that women aged 40-60 who are not physically active also get this, which is thought to possibly be related to a hormonal imbalance.
Rehabilitation
Treatment of HT requires time, patience and a gradual approach to rehabilitation. Here is a four-stage rehabilitation protocol that is often used to restore strength and function in the hamstrings and associated muscles:
Phase 1: Isometric/static exercises without hip flexion. The focus in this phase is to reduce the pain by activating the hamstring muscles without loading the tendon attachment too much. Exercises such as the single-leg hip bridge and isometric leg curl exercises are often effective for strengthening the muscle and reducing pain. The aim is to stabilise the area before moving on to more dynamic training.
Phase 2: Isotonic exercises with minimal hip flexion. Once the pain has subsided, more dynamic exercises can be introduced. This can include the leg curl machine, prone leg curl and slightly greater range of movement. The aim here is to build strength and endurance in the hamstrings without provoking the tendon attachment too much.
Phase 3: Exercises with greater hip flexion (70°–90°). Here you begin to introduce exercises that give more functional strength in positions similar to what you do during running. Exercises such as hip thrusts, lunges and deadlifts can gradually be included. Controlled technique is crucial to avoid overload and relapse.
Phase 4: Energy storage and explosiveness. In this phase the aim is to get the muscle-tendon unit ready for the load that the sport requires. For runners this often involves exercises such as sprint movements, kettlebell swings and dynamic jumps. It is important to gradually resume explosive movements, and here it is recommended that you monitor your pain carefully so that you do not overload the tendon.
Pain relief and additional treatments
For acute pain, anti-inflammatory medicines such as ibuprofen can be helpful, but they should not be used for a long time as they can potentially inhibit tendon healing.
Passive treatments such as shockwave therapy can also be useful for relieving symptoms, but these measures will not replace the necessary rehabilitation exercises. Cortisone injections can be a solution for temporary pain relief, but it is important to remember that this often has a short-lived effect and, at worst, can be harmful to the tendon structure.
When can I start running again?
A gradual return to running can start when you can perform the rehabilitation exercises without significant pain (a maximum of 3 out of 10 on the pain scale). It is important to avoid progressing too quickly, especially when introducing hill intervals or fast running, as this can be provocative for the tendon attachment. Many runners find that they can resume running on flat ground before they begin more intense training.
It is also important to be aware that sports with rapid acceleration, such as football, require an even more gradual progression because the load on the hamstrings is greater.
Conclusion
Hamstring tendinopathy is a common injury among runners and other athletes, but with the right treatment and gradual rehabilitation, most people can return to running and physical activity without relapse.
The most important thing is to listen to your body, avoid sudden increases in training and carry out a well-structured rehabilitation programme. With patience and consistency, you can regain both function and performance.