Proximal Hamstring Tendiopathy

Proximal Hamstring Tendinopathy - or PHT

The pain is much higher up than what people would typically recognise as their hamstrings. It's specifically around the ischial tuberosity of the pelvis (the sit bones > anatomy slide) & so easily irritated by sitting on hard surfaces or for long periods & excessive stretching into positions like downward dog.

As with all tendon issues, Proximal Hamstring Tendinopathy comes on from an increase in load i.e. hill running, deeper lunges, heavier deadlifts and certain yoga positions. It is most likely stiffer and sorer in the morning with a tendency to warm up with exercise.

How to manage acute symptoms...

Stop stretching! EVEN downward dog poses. The tendon does not like this compressive position (neither do I by the looks of my lacking technique!)

Sit on a softer surface & try to avoid sitting for long periods at your desk or for car journeys.

Running wise: avoid hills & speedwork. Try to maintain minimal to no pain during & after exercise.

Make sure you have recovery days - the tendon needs that to adapt.

Once you've got it under control, like with other tendon rehabs - it needs LOAD. 

Hip-dominant hamstring isometrics

Prone hip extension: engage your core, keep your knee straight & lift leg 1-2inches off the floor

Hip extension hold: lying on your back push your heel down into chair or step & hold

Double & single leg hamstring bridge hold. The difficulty is dictated by your foot placement - the further away from your hips, the harder it is on your hamstring.

Find the exercise that loads the hamstring sufficiently to fatigue after 45secs (X4) but not to aggravate your pain levels.

Hip Dominant Isometrics

The hamstrings cross both the hip & the knee. In order to target the proximal hamstring tendon in the early phases, we want to load into hip extension.

PHT Exercise progressions...

We swiftly move on from isometric holds to challenge the soft tissues through the range.

Double & single leg hamstring bridge: increase the challenge by tailoring your foot placement. The further your feet are from your hips, the more challenging. Ensure they are challenging but that you can do 8-12 reps.

Hamstring sliders: try to keep your hips elevated as you extend your knees. (This can be done with socks on a hard surface). You should NOT feel this in your back. If you do, reset your pelvic tuck & core before lifting your hips.

Banded hip extension: attach a band to the other leg (or chair). Keep your back straight and extend through your hip. Early stages - avoid leaning fwd as this increases tendon compression. (We will build in this tolerance in the later stages).

Compressive loading for the PHT…

This injury often comes about from too much- too soon, but also compressive forces can overload the proximal tendon.

This does NOT mean that going forward we want to always avoid compression. Firstly this is near impossible as it is inevitable in most daily tasks; walking, climbing stairs, sitting etc. Secondly, we can teach our body to tolerate most loads if we are progressive & adaptive.

Instead, we want to build in our tolerance to them with these specific late-stage exercises.

Good mornings: slight bend in one knee as you hinge through your hips keeping your back straight & chest up.

Single leg RDL: slight bend in standing leg & hinging through hips to lean fwd, feeling hamstring pull as you keep your hips square to the floor

Banded hip extension: now with forward lean

Step up with forward lean: highly functional & works the glutes too as you drive up through the front leg before slowly lowering back down.

For more information and exercises…

Head to @lucytriphyio on Instagram

Email - lucytriphysio@gmail.com with any questions.