Proximal Hamstring Tendinopathy (rehab)

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Hello all, I’m trying to learn how folks here have rehabbed and recovered from proximal hamstring tendinopathies.

I’ve been dealing with a proximal hamstring tendinopathy for about 6 months now. It started acting up in the spring in the middle of training for my 1st full distance triathlon. After lots of uncertainty about what is the pain driver (PT, massage, osteopath, primary care, …) I finally got an MRI. Diagnosis was a complex labral tear with proximal hamstring tendinopathy (PHT) as well as some tendinopathy in the glute medius/maximus.

After 3 additional months of PT and no running I got to see a hip surgeon (expert on labral tear repair). After thorough examination he is convinced the labral tear is not the pain driver and all my issue stem from the PHT. His suggestion was PT and slow return to sport. A platelet-rich plasma injection would also be an option, but his suggestion was to wait with it.

So my current plan is to stick with 4 weeks of total rest. Then proceed to PT for PHT and cross training (e.g. rock climbing) to get active again without the danger of aggravating the hamstring tendon in any way. After another 4 weeks of that I’m planning to bring in low-stress cardio (e.g. elliptical). And after another 4 weeks I’m planning to test the waters with some light running and biking.

It’s frustrating to deal with an injury that doesn’t really have a clear path to get it fixed. On the other hand, it’s probably a better place to be in that having the labral tear requiring surgery or ultimately needing a THR.

It would be great if others could share their dos and don’ts for recovery from a PHT. And if anybody got a platelet-rich plasma injection, I wonder if you think it helped.

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Yes, I overcame mine.

It started in mid 2021. After some fairly fruitless treatment (shockwave), I found an excellent physion (Stuart Butler, UK, Guildford) who prescribed the classic tendinopathy progression: isometrics, eccentrics, heavy slow loading. This was done via single leg glute bridges, with the affected leg elevated. See Foot Elevated Single Leg Glute Bridge - YouTube

We started off with 2 sets of 5x5s holds, then moved to 2 sets of 5x15s holds. When that was reasonably manageable, I moved to eccentrics (raise with 2 legs, then lower, over a full 10 seconds, with one). Then I added weight to that move, either by having a db on my lap or by having my wife push down on my hips on the eccentric.

The next stage was to do the full, single leg raise, with weight, with a 5s positive and negative.

This isn’t a recommendation, by the way - you’d need to see a physio for that - but it’s what I did which I believe is a very orthodox PHT rehab plan.

It was a process, sure but after around a month I saw real improvement, with more or less complete resolution after 3-4, through I understand that’s a bit quicker than average.

While rehabbing it, I was told it’s fine to keep riding, but to really minimise hills, aero positions, and hard efforts. I pottered round on the hoods in z2 - or stuck to the trainer (riding mainly on the tops at z2 and tempo), which was a godsend for me.

The final suggestion I’d consider is a bike fit. I have to run my seat height 10-20mm lower than most orthodox bike fitters recommend, but I’m a heel dropper, and that gets worse if I go hard up hills.

I still get the odd day when i wake up and it’s a little sore, but a week of daily isometrics always sorts it.

This is fixable, but you need to have a plan and be consistent. Good luck.

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This is almost always a bad idea, btw. Tendons need loading to remodel. Resting will take away the pain but as soon as you return to activity, it will (usually) recur.

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Thank you for the perspective. Very much appreciated. It’s great to hear stories of success in the sea of drawn-out horror stories. The PT plan you followed is very well aligned with what I worked out with my PT–so good validation there as well.

I totally hear you on the bike fit. Both my bikes (road/gravel and tri) are pro-fitted. But one piece of intel I got from a shop manager is that a lot of PHT is caused by long hours on a trainer. For one, people don’t move or even shift their weight. So hamstring tendons are continuously irritated without any relief. In addition, many tend to shift their weight backwards on the saddle during hard intervals to generate more power which further grinds the tendons between sitbone and saddle.

As for the rest, I don’t see it is curative for the underlying problem. I just want the irritation and inflammation to die down a but so I get a better feel for how far I can push during the recovery rehab and return to exercise.

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Long story short I have this and have not really seen much improvement over the last month. Came down with it two months ago and it took about a month between Xrays, MRI and Dr. diagnosis.
I have been doing bridges and other strengthening exercises of the hamstrings and gluts.
I wonder if I need to scale back to every other day on the strengthening?
Can others on here give me some suggestions? Also my insurance does not cover PT which is insane IMHO but to be honest the PT wasn’t much help to begin with.
Any experience with this injury would be appreciated. I haven’t been able to run in two months and its driving me crazy…

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Hi Michael, I am really sorry to hear that you are afflicted with this. It’s a terrible injury–for body and mind. That said, I want to tell you there is light at the end of a possible long and dark tunnel. It took me about 18 months from 1st injury to competing in my first triathlons again. Unfortunately, I got sidelined again by a different injury (sustained during PT) – but that’s another story and hopefully I’m over that one by now as well.

To be honest, you don’t need regular PT appointments if you are accurately diagnosed. The key exercises and progression is well-described on the web (YouTube and dedicated sites). And the exact details are person-specific, so you need to calibrate them as you go along.

Here are, what I now strongly believe are the three main principles to get you better:

  1. Follow a protocol that provides increasing load/strength exercises for the hamstring tendon (or any other tendons afflicted e.g. adductors). Progress from isometric to eccentric to dynamic exercises.
  2. Calibrate all exercises (PT and anything else such as hiking, lifting, walk/runs, swimming, biking, elliptical, …) so that you do feel discomfort during or after the exercises, but the pain has to return back to baseline within 24-36h.
  3. Keep a highly detailed pain AND exercise log where you note your pain level (ideally every morning and evening) and all activities you did that could potentially affect the pain.

The idea behind this is pretty simple: The PT program (point 1) has been shown in multiple studies to be effective in many cases where there is no injury to the tendon that would require surgery. This can not be said for any other intervention such as shockwave therapy, needling, PRP injection, steroid injection, …

The second point is based on the also proven fact that you do need to load the tendon to induce healing which causes discomfort. The thought is that if pain returns to baseline in a day or so, then you did enough to stress the tendon, but did not do any further damage that would set back the healing process.

The final point is something that is not often talked about, but it was crucial for me. If you do daily exercises (PT and other workouts) and push yourself, it is very hard to figure out what is too much and what is not. And if you push yourself in 5 different PT exercises all at once while you are also trying to get some cardio in, it gets even more complicated. This is where the detailed log comes in. Push yourself, but vary your exercises daily. If you then keep a written log (best in Excel so you can even plot various things out) you should be able to figure out over time what is well tolerated and what is not. That allows you to pile things up and progress in some areas, but still be slow and cautious in others.

Bit of a long story and I wrote this rather stream of consciousness style. Let me know if you would like more info (I got it in spades) or further explanations. Keep up the good fight!

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Thanks so much for your response, it is really appreciated. Do you mind going into more detail about “isometric to eccentric to dynamic exercises”?
I have been doing one legged bridges and have recently added weights. Also I most recently found when doing the bridges not leaving my one foot flat but at 45 degrees. Also instead of doing reps I am holding for one minute at a time. Wow can I feel my hamstrings…
I am feeling discouraged at this point because I honestly dont feel like I am making any progress.
Lastly, do you work on the strengthening every day or every other? I am doing a lot more walking and biking now to supplement the not running but I dearly miss not running!!!
Thanks again!!!

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Hi Michael, honestly, I can’t make a recommendation about the frequency of strength training. It is highly individual and dependent on the exact nature of your injury and workouts. That’s where point #2 and #3 of my previous post come in: You need to figure out if you tolerate daily strenthening. If you do (pain/discomfort returns to baseline by the time you are ready to start the next set), then go for it. If you don’t, wait an extra day and reduce the load/challenge/duration/reps of the exercise that is driving the pain.

Working this out is a challenging process. It took me about 3 months to pinpoint what was too much and what was just right. But once I had it dialed in, it became easier to slowly progress.

I found this video (https://www.youtube.com/watch?v=uzbg4ZOWwoQ) a pretty good overview of the progression for PT. Once you’ve seen this you can start googling for more exercises that best suit you.

The other resource I’d recommend is a FB group: “Proximal Hamstring Tendinopathy Help and Support Group”. You’ll find many people in the same boat as you and can ask for additional clarifications and help.

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Thank you and I had previously watched that YT video but honestly I have watched so many I lost track. I will def follow your suggestions and the ones on this video. Also I applied to join that FB group along with a couple others relating to this issue.
I suspect my expectations of how quickly I am going to notice changes and reality need to aligned. Patience is not one of my better virtues…LOL

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Sorry to hijack this but what was everyones initial symptoms? I’ve been having bad ischial tuberosity pain when riding MTB. Tried multiple bike fits, saddles, etc and still have it. Worse with climbing no doubt. I don’t run but it doesnt seem to bother me too much off the bike, it does feel more bruised in that area of the ischial tuberosity and slightly at the tendon.

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Yes, adjustment of expectations is the tough part. I went through my own peaks and valleys of hope and disappointment. A clear attitude shift came when I realized that some live with excruciating pain from this condition forever. :disappointed:

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Bursitis was definitely part of my first symptoms as well. However, there are a few movements that are clear pain-drivers for PHT which will distinguish it from other diagnoses. Bursitis in particular will go away with rest and icing – PHT will not.

For me one of the most reliable pain driver was pulling of a tied shoe from my injured leg with the other foot while standing upright. That pulling motion on the leg caused a sharp pain right underneath the butt. I also used this movement as one of my ways to gauge daily pain levels.

That said, I would make an appointment with a PT or a doctor who has some experience with PHT. It should be relatively trivial for either to make a differential diagnosis.

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Hi all,
did any of you had an actual tear of the hamstrings tendon? Did it heal with PT?
I am considering surgery, as I had PRP twice, did lots of PT, but no improvement after 5 months… On MRI: tear remains the same…
grtz
Leen

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I dealt with PHT about 15 years ago. It stemmed from running many marathons as I wasn’t a cyclist at the time. My financial position was much different back then so I didn’t have the money to do much therapy other than a doctor visit and some PT. This got me back to running, but it was slow. Anytime, I opened my stride up for faster paces, there was considerable pain. I had an MRI and there was no tear. After a year of minimal improvement, I researched stem cell and PRP options. I chose to have PRP injection in the hamstring, near the ischial tuberosity. I had another 3 weeks of no running, but I did some light stationary cycling to try to keep up fitness. After this period, I resumed slow running, every other day (15 mins) and building up. After about 8 weeks, I was running 40 mins and then began running 5 days a week. PRP was the only thing that really “cured” me. I still have occasional tightness, but it is typically when I veer from my PT routine of stretching hamstrings and strengthening them.
Back when I did PRP, it wasn’t covered by insurance (I’m in US) and it was rather costly, but, to me, worth it.

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Sorry… didn’t see this earlier.

If you have a complete rupture or avulsion, then no amount of PT will fix it – only surgery. But if the tear is partial, the answer is ‘it depends’ on the extent of the tear.

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PRP seems to be a real mixed bag… it seems to work wonders for some while it has no effect for others. So far the RCTs have not shown any convincing benefit across the population, but maybe eventually we will figure out why it works for some and treat those preferentially.

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I have had both a minor tear in 1 calf and a complete tear ( muscles from tendons) in the other calf. 1 healed on its own and one required surgery.
I did have gluteal tendinopathy with bursitis. Steroid shots and muscle relaxers helped it heal with PT. Took a lot of months.
For a complete tear surgery will most likely have to happen according to my orthopedic doctor.

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Just my 2c worth.

I’d endorse what MarioN and co are saying about progressive loading.

My key points to patients are:

  1. Tendons are super good at withstanding tensile loading, this is what they are designed to do. The problem with the proximal hamstring is that as we move further into hip flexion, we start compressing the front of the tendon around the ischial tuberosity, resulting in the hamstring action causing a combined compressive/tensile load through the tendon, which they are not structurally designed for. Thus initial loading tends to try to avoid this combined compression/tensile load - and why your bridges are a good start.

  2. I use the picture of a tendon looking like a collagen “paint brush” - super strong if you pull those fibres, but bend them and they tend to fold. The body’s response is to throw down a different sort of short curly collagen fibres and then glue it all together with a sort of protein cement. This high molecular weight protein “cement” attracts water at rest, which is responsible for the start up pain people notice (incidentally helping it withstand compression as it acts a little more like cartilage now). As you move, you pump this fluid out so things feel more comfortable. Similarly, if you massage a tendon, you move that fluid out so patients report that it feels so much better, but because you are not inducing structural change in the tendon, the relief is short lived at best.

  3. The idea of rehab is to challenge the tendon to remodel that “repair” back to “normal” tendon. By their slow metabolic/poor blood supply nature, this is SLOW in tendons, hence the 3 month time line. So don’t expect overnight changes, but similarly happy for you to continue to load progressively over that time. In fact if we biopsy your tendons at 3 months, those structural changes wont be complete even then, but hopefully functionally you will be pretty good. Once you’re good with the “safe” positions, we can start challenging the body into more and more niggly one’s e.g. starting to get more hip flexion.

  4. Another key message is that rest is not particularly helpful. In animal studies where they enforced rest, they needed to double the amount of work to induce these structural changes. These tendons need to be challenged to change, and are metabolically slow. This is why we need high volume loading. 3 sets of 8-10 is not enough. Successful studies have looked at something like 90 repetitions per day.

  5. Last point is that tendons are notoriously unreliable pain signallers. After they have told you that they hurt for a while, we saturate those channels and they just stop telling us. Our most reliable indicator of loading is your 24 hour response i.e. What does it feel like the following morning. If you mentally give yourself a 0-10 score on how sore you are each morning on waking and you find yourself sitting at a level you are comfortable with (different for everyone), then your loading is probably about right. If you wake up and it was a 3/10 yesterday, a 6/10 today and tomorrow is a 7/10, you’re probably pushing a little hard. Keep some loading in there but try to let it settle back to an acceptable level before you go and repeat that stimulus.

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Hi all, sorry for jumping on tbis trend. Im 20months woth PHT. I was misdiagnosed initially with Sciatica and was rehabing that. Between different physiotherapists ive been with once since March and knew the process would be slow. But i really feel im taking two steps forward, 4 steps back at times. Im really interested on peoples experiences with injections, please

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I had a complete tear of my conjoined tendon with 2cm of retraction in 2022. With lots of PT, I recovered very well with no surgery. Over 2 years later I’d say that the side with the tear is 90-95% of my non torn side. The only time I notice that 5-10% is during isolated hamstring curls. I have Garmin rally power pedals on both sides of my bike and my breakdown in power is usually a perfect 50/50 or occasionally 49/51.

I also triggered a labral tear the following year, and no amount of PT will compensate for that. The hip pain from a PT tear (that is significant enough to need repair) is VERY obvious. It feels buried right in your hip socket. Many people have labral tears and they’re never diagnosed and never an issue. I’m 10 months post op and while not perfect, vastly improved from before. I’ll likely get my other hip fixed in a couple years. It’s uncomfortable occasionally but not near the extent on the one I had repaired.

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