Literature can be found on various running related injuries including those involving the hamstrings, however there is a lack of research on the treatment of (PHT) A.K.A. high hamstring tendinopathy. PHT may arise after an acute tear of the hamstring musculature at its origin or, as in most cases, is due to overuse. It typically occurs with repetitive jumping, kicking, and running since the hamstrings contribute to the decelerating of knee extension during these activities. (Peterson J. et al, 2005)
Although hamstring tendinopathy may occur at the distal segment near the knee, PHT occurs at the common origin of the hamstring muscles, the ischeal tuberosity. The injury is usually characterized by pain near the ischeal tuberosity (deep buttock pain) and may extend down the posterior thigh. Common symptoms include pain with prolonged sitting, pain with forward flexion of the trunk, and pain with running. (Maeyer)
Current treatment options include surgery, shockwave therapy, eccentric exercise, core stabilization exercise, corticosteroid injections, and massage/soft tissue mobilizations. The most commonly accepted therapeutic approach to treating a tendinopathy is eccentric exercise (this was also talked about in a previous post, check it out!). There are several reasons why eccentric exercise is used to treat a tendinopathy: a greater tendon load is generated eccentrically compared to concentrically, increased collagen synthesis, decreased neovascularization, and force fluctuations from tendon loading and unloading. Several common eccentric hamstring exercises include hamstring curls, reverse planks, Nordic leg curls, and single/double leg dead lifts. Most of these exercises focus on resisted knee flexion rather than hip extension. It is important to differentiate between the two functions on of the hamstring muscles (knee flexion, hip extension) due to the location of the tendinopathy and that runners primarily rely on hip extension, more so than knee flexion to increase their speed. (Cushman et al, 2015)
Alright, so we know what the issue is, we decided eccentric exercise is the best conservative treatment option and we listed several common eccentric hamstring exercises. Problem solved, right? Wrong! This traditional approach sounds great, however symptoms still often persist requiring us to find another conservative treatment option to avoid surgical intervention.
In the latest edition of JOSPT there was an article published by Daniel Cushman and Monica Rho titled “Conservative Treatment of Subacute Hamstring Tendinopathy Using Eccentric Exercise Performed With a Treadmill: A Case Report” (3). In the article they described a 34-year-old male triathlete who suffered from PHT. Initially he was treated with 4 weeks of traditional eccentric knee flexion exercises and core stabilization exercises, however found little relief. An eccentric hip extension exercise involving a treadmill was initiated for the following 4 weeks in an attempt to target the injured tissue (the tendon at the origin of the hamstrings). The eccentric hip extension treadmill exercise was performed 1-2x daily for 3 sets of 15 repetitions. In the case study, the patient noted a decrease in pain within 2 weeks of starting the treadmill exercise and was able to return to gradual running at 4 weeks.
Here is a description of the treadmill exercise:
The level of evidence for this new intervention is limited due to the current study only having one participant. While this means there is not an overwhelming support for its use and effectiveness with the current evidence, the intervention should not be discredited. The eccentric treadmill exercise was developed with sound clinical reasoning and is easy and quick to perform. Hopefully given the results of the current case study, a larger study with more participants will be performed revealing whether the treadmill exercise warrants implementation. Try the exercise out for yourself and let us know what you think!
Also, be sure to check out the entire article for yourself!! (citation below)
(1) Peterson J, Holmich P. “Evidence based prevention of hamstring injuries in sport.” Br J Sports Med. 2005 Jun;39(6):319-23.
(2) Maeyer M. “Hamstring origin tendinopathy.” Physiopedia, universal access to physiotherapy knowledge. http://www.physio-pedia.com/Hamstring_origin_tendinopathy
(3) Cushman D, Rho M. “Conservative treatment of subacute proximal hamstring tendinopathy using eccentric exercise performed with a treadmill: a case report.” JOSPT. 2015 July:45(7)557-562