Proximal Hamstring Tendinopathy

At least, now it has an official name... I'll be back on this in a moment.

The London Marathon is behind us, and I participated to it as a spectator. That wasn't the plan -- of course -- and, instead, I made a brief visit to the famous Eagles Cheer Squad at Mile 23. It was really exciting, I have to say: the level of support given to our runners is truly amazing. What an energy and confidence boost it must be! This made me even more eager to get back soon to running, and start training for 2020 VLM. In all honesty, I need this strong motivation, because the path is still quite uphill, as you'll understand if you read below...

Let me use this last blog post to talk about the condition that is keeping me out of running since February/March. I hope that this could be useful to other runners of the club, by raising awareness on this nasty, mainly running related, injury. It's official, I have "Proximal Hamstring Tendinopathy", which could be briefly described as a degenerative state of the upper hamstring tendons (where they attach to the ischium bone -- deep in your buttock, to be clear!). It is a result of repetitive micro trauma of the tendons, that result into an inflammation of the tissue and, finally, into a chronic degenerative state of the tendon itself, if not treated promptly. Unluckily, my right leg tendons are in this degenerative state.

The good news is that this is reversible. The bad news is that it can take a long time: evidence suggests a 3-6 months recovery time, provided the correct protocol is followed. I'll give you below a quick overview of causes, symptoms and possible treatment (disclaimer: it's clear that you have to be diagnosed by a doctor, and that the treatment has to be overviewed by a physio).

Causes

Proximal Hamstring Tendinopathy is caused by an overuse of the hamstring tendons. The main risk factors include:

- Muscle imbalance. I can mark the check-box here: my right leg turned out to be far weaker than the left. Physio even measured it, and noticed a 2 cm circumference difference at the thigh level.

- Poor running form. This is mainly due to the famous forward pelvic tilt, which is typical of all of us spending most days in sitting position. When the pelvis is rotated forward during running, we tend to use less the glutes, and to load more on the hamstring (this is often referred to as "running sitting on the saddle"). I can mark the check-box here, too. :(

NOTE TO PLANTAR FASCITIS SUFFERERS: anterior pelvis tilt also leads to overload of the foot arch, which is one of the main causes of plantar fascitis. Correct it (see the "TREATMENT" section below) and you'll likely help your feet healing from PF. If you want to test the effect of forward pelvic tilt yourself, try this: stand tall, extend your arms upwards as far as possible (this will put your pelvis in the correct position), then lower your arms but keep the pelvis fixed (engaging your core muscles will help). Then do a few steps keeping yourself tall, core engaged and paying attention to not rotate the pelvis forward: the steps should feel light, with the feet naturally touching the ground right below you. Now, disengage the core, hunch a little bit, like if you are very tired, and don't stand as tall as before (you are now sitting a little bit on your legs). Take a few steps... You should feel the additional load that you are putting on the foot arch and on the hamstring.

- Too much stretching. Yes, stretching can be bad if in excess quantity, especially if applied to a muscle/tendon structure that is already inflamed. I have to mark the another check-box: basically I have done everything conceivable to irritate my hamstrings!

- Age. Of course... :|

Symptoms

The typical symptoms are:

- A pain deep in the buttock, and sometimes down the thigh. This is similar to the symptom of piriformis syndrome (and associated irritation of the sciatic nerve): this is why a proper diagnosis is needed, to distinguish between the two conditions (which require different treatments).

- It feels painful bending down to tie the shoe laces, or to pick up an object from the ground.

- Sitting for a long time can cause pain, and driving in particular (because you exert pressure right on the attachment point between hamstring and the "sitting bone").

Treatment

Finally we come to the treatment topic. As mentioned at the beginning, depending on the severity of the case, it usually take over three months to heal, even if the proper protocol is followed. Note also that, apart in the initial acute phase (when you feel most of the pain), rest is not very helpful to heal from this injury: being a chronic degenerative state, if no active action is taken, it can last for years, becoming a career ending condition. So what's the proper treatment?

- Phase 1: The first aim is to reduce the pain. At this stage (and only at this stage), rest can help. Also, anti-inflammatory drugs can be used (Ibuprofen & co. are known to interfere with the muscle repair process, but they can still speed up recovery from the initial acute-pain phase, shortening the overall healing time. I didn't use any because in my case the pain was not that bad...).

- Phase 2: When the pain is sufficiently reduced, it's time to reverse the tendons degenerative process. It has been found out that this can be achieved by means of isometric and eccentric loading. In the first few weeks, you can start doing isometric loading (that is loading the muscle in a fixed position). Typical exercises involve leg bridges and side planks every other day. Once isometric loads are bearable without much pain, you can proceed to eccentric exercises (where the muscle is loaded while you are extending it). Common eccentric exercises are leg curls, nordic curls, etc.

- Phase 3: At this point, the pain should be dramatically reduced (I position myself between phase 2 and 3, at this very moment). Now it's time for exercises involving full range of motion, such as lunges and squats. At the end of phase 3, to favour return to running, plyometrics can be performed, such as frog jumps, lunges with jumps, etc. Once phase 3 is over, one can restart training normally, increasing the volume and paces to pre-injury levels. What about running during recovery phases 1 to 3? It is OK as long as: 1) It is performed at and easy pace 2) it  doesn't cause a strong pain 3) the residual pain after the run disappears within 24 hours.

- In addition to what listed above, it is of extreme importance to strengthen the core, and to fix the pelvis tilt. Strengthening the core helps in further reducing the load on the hamstring during running. Also, a strong core is necessary to prevent the pelvis from rotating forward (the negative impact of this rotation has been highlighted above). As already mentioned, the forward rotation is typical of people sitting for many hours every day: that's because it leads to the shortening of the hip flexors, so that they will tend to pull you pelvis down. Given this, it is of uttermost importance to stretch regularly the hip flexors in order to restore the correct hip position!! I know, it's very boring doing this stretches every day, but think about this: longer hip flexors allow you to extend your legs further backwards during the push off; and this increases the running efficiency, making you a faster runner (for instance, at the moment I have lost my cardio fitness, but the strengthening exercises, all the stretching of the hip flexors and the correction of the pelvic tilt have already made me a better runner: last week I made a few strides, and I can run them much faster now than when I was very fit pre-injury!!). As an added bonus, if by stretching the hip flexors you allow for a better pelvis position, you're likely to fix any problems with the plantar fascia.

The final message is: hamstring tendinopathy is a very nasty condition, but it can be corrected. It requires, though, a lot of motivation and discipline (doing the hamstring and core exercises every other day for MONTHS!).

I really hope this will help others to avoid getting this kind of injury. Remember that early signs can be tightness in your glutes and lower back and hamstring soreness. So, if you feel any of these, watch out ;)

Finally, massive congratulations to the all the Eagle that finished the VLM this year!

I'm going to do my eccentric exercises now... 

===============

Not a VLM blog anymore

First of all, apologies for being so late with the blog. But the truth is that not much really happened in these last four weeks. I'm religiously following the plan laid down by the physiotherapist at Move, and slowly begin to feel the beneficial effects of it. The muscles around the hip have become stronger, and the hip seems to be more stable. I've also been able to run a few times, without pain. I mainly focused on keeping a good form, and improving the technique, so to reduce the future chances of getting injured again (and, hopefully, to improve the performance, too...). 


On the other hand, my fitness has been hit really hard by these weeks of rest. I can feel the fatigue just after one or two miles, and the heart rate clearly rises after three. I know that this is normal, and temporary. But nonetheless frustrating. I look at the Strava feed in awe: many guys and ladies in the club are doing amazingly well in training for the spring marathons, and ran truly fantastic times in the tune-up 10ks and half marathons (side note: The Big Half should have been one of my tune-up race, that I had to give up. I'm quite disappointed that they do not allow either deferrals or transfers. I won't sign up again. Full stop). I can see the level of the club constantly improving, old members getting faster and faster, and new young members which are showing brilliant performance. BTW, as a consequence, the contest to get on the WCR bus has never been so exciting! And I can't deny that I am a little bit depressed at being forced to be just a spectator... Trying to stay positive, and to find an upside, I keep looking at my fellow runners brilliant training and races to find greater stimulus and determination for my come back. I need this, especially now, to keep going when I feel so heavy and sluggish during my (few) training runs, between a (booooring) strengthening session and the other.


When I started feeling the pain in the leg, it was still mid January, and I hoped to quickly solve the issue to get back on track. Things took a quite different turn, and the problem revealed to be much worse than initially thought. As said at the beginning of this post, I am now seeing the light at the end of the tunnel... But for what concerns the London marathon, it is clear that the time has run out. At this point, I can take it easy with my rehabilitation: I won't rush it, and take all the time needed to be able to properly train and run again. I would like to be back for June/July, maybe initially focusing on short distances. In particular, I hope to run again the Sri Chinmoy mile relay in July (Kieran, Briain, don't rush finding a replacement, please!!! ).


So, in this VLM blog I won't talk any more of VLM. In the next post, though, maybe I'll talk a little bit about how I am changing my running form and posture (following physio advice, and suggestions from a few other credible sources). It might be interesting to those plagued by plantar fasciitis, because one beneficial side effect of improving the running technique is that it tends to reduce/solve that kind of problems (as I am experimenting on myself).

A short update

This is going to be a short update. In fact, during the last two weeks I had to further reduce running, down to a nearly 0-km-a-week level. :-( The inflammation to the upper hamstring is reducing very slowly. And to make the situation worse, other nasty niggles appeared in the previously healthy parts of the right leg. It really feels like all of this resting and strength training is having the opposite effect than the intended one. But I guess it's just a matter of patience, be disciplined, and follow the plan laid down by the physiotherapist... I'm meeting with her again in a week time: we'll reassess the situation, and discuss the options to move forward. It's clear, though, that I see my chances of quickly getting back on track thinning out every day that passes.

After two years of being injury free, it is really very frustrating that this setback had to happen right in the build up for the London Marathon. Even more, because I got the place through the club, and I feel the commitment of delivering my best performance. Anyway, striving to see an upside, this is going to be a good occasion to sit down and think about the causes that led me into the current situation. Some have been already highlighted by the physiotherapist (the imbalance between my left and right leg, weak right glute, etc.), but I can foresee others, although they might all be -- somehow -- connected. Last week, I received a gift from my wife, the book "Your Best Stride", which analyses some of the common problems in the posture and gait of the amateur runner, and give suggestions and proper exercises to correct them. I have to say that I've just started reading the book, after briefly going through the various chapters to get a quick picture of the main ideas. It's some paragraphs dedicated to hip mobility that attracted my attention. Indeed, I remember an increasing stiffness in my hip in the period that led to the injury. Spending many hours sitting doing my job (researcher and software developer) I am not surprised that my hip becomes a little stiff at times. But I've never thought about the implications it could have on my running. Thinking back, I clearly remember how fluent and light was my stride at the beginning of last year, when I had no issues with the hip. And, on the other hand, that feeling of "pounding on the ground" in the second part of the year. Something happened, and I'm pretty sure that has to do with my hip. 

Looking ahead, I'm going to work hard to fix the issues with the leg and the hip. I am sure I'll come back stronger... Not sure how long it will take.

The Old Scar

It happened during the winter, seven or eight years ago, I don't remember exactly, when I was on holiday with my parents on the mountains. Every year we rent a house in Madesimo, north of Italy, and we go there for skiing, which I truly love. The days, there, follow a precise routine... First, my mother comes to wake me up. She has this lovely habit of entering quickly into my room, going straight to open the window, letting the freezing air (we're talking about -5°C or less) send a shock through my body. At that point, I usually run into the kitchen, next to the fire stove, where breakfast is waiting. There, I also meet my father, which starts immediately putting pressure because "we are late, and the ski-lifts are already getting crowded" (even in those days when there is absolutely no one around). After breakfast, I quickly dress, and start doing some warm-up exercises. Well, I WOULD do the exercises, if it wasn't for my daddy hitting me again with the "we are late" thing, and arguing that warming up is useless. Indeed, this works well for him, apparently. But not for me!

So it happened that, in order to avoid the non-existent queues at the ski-lifts, one morning I skipped the warm-up. We went straight out, and started skiing down the slopes (the house is adjacent to a piste). It took less than a minute. That feeling of... tearing. And the right hamstring was gone.

After many years, the scar that resulted from pulling the hamstring is still there. It seems that I didn't do the proper physiotherapy to recover and thus, once it healed, it was slightly shorter than before (actually, I went to physio only one month later, bad decision). So even now, when I run, the right hamstring tends to be a little overloaded, with all the consequences that you can imagine. To counter this, I have to be very disciplined, and include some good stretching after each run.

Now comes the bad news. During the stop before Christmas (see previous post) I didn't do much stretching (actually, no stretching at all), and when I started my marathon plan, that nasty little scar began to do its job: slowly wearing my right leg muscles, run after run... until when, a few days ago, I felt that something was hurting. I did the sensible thing, and stopped running, walking back home. I hate that moment, when that name takes form in your mind: "MOVE clinic". And there I went. The response is that the upper hamstring tendons are slightly inflamed. I have to reduce running to a minimum for a couple of weeks, and I have a beautiful strengthening plan to follow. Ah, in addition I had the chance today to have lot of needles put into the leg and the glute, the dreaded acupuncture. I realised though that it's not that painful, you feel just some "tingling"... 

What about the marathon? It depends on how I respond to the treatment: I hope to be able to soon increase the running volume again, but the good guys at MOVE will have the final word. Wish me luck!

Take-home messages:

- Do a proper warm-up: ALWAYS.

- After an injury, ask for professional help, and do the proper treatment, or you can pay for YEARS.

- Do not always listen to your father (well, just sometimes)

- Acupuncture is not painful (I really thought it was)

In the middle of the night

I lost the sense of time, and when I went to sleep that night I wasn't thinking about the VLM ballot. There is indeed a seven-hour time difference between UK and Vietnam, where I was spending my honeymoon, and I falsely believed that the Eagles Christmas party would be on the following day. It happens, though, that the local beer is given away for less than one pound a pint... This meant that I had to wake up in the middle of the night, when nature called. Crawling back to the bed, the flashing light of the phone attracted my attention. A message from Sonja Knoll: "You won the ballot!". Then I fell asleep again.

Only in the morning I was able to fully grasp the news, and share it with Sara, my wife (while double checking the phone to verify that it wasn't just a dream). Oh yes, I am running the London Marathon! Excitement! A LOT of excitement!! And then doubts... It would be my first marathon. It is only four months away. And I spent the last ten days mainly eating, drinking, getting happily fatter and "unfitter". Well, the lifestyle didn't change much after that day, until the end of my holiday. At least, I made good use (a few times) of hotel treadmills, and I proudly came back to London without a ZERO on the last two weeks Strava mileage.

Not a zero, but not a large number either. After I came back, given the importance of the event, and that little pressure induced by fellow runners (Kieran has been quick to remark "The weight of the club is on your shoulders!" -- thanks Kieran! :DD), I felt the need to devise a sensible plan. It needs to bring me from the Christmas 20km per week, to marathon fitness on the 28th of April. Tight. However, before going to the details about my plans, let me explain why I entered the club ballot for the London Marathon.

Apart from the obvious answer (I want to run the VLM!), the main reason is that I was waiting for a "sign". Something that could give me the courage to step up and go for the full distance. After having raced on the most common distances, and having done a few half marathons, I felt the need for a new challenge. But, perhaps scared by the required training effort, I kept postponing the decision to go for it. So I said to myself: "Only if I enter the famous London Marathon -- one way or another -- I'll start training for the 42.2k" (BTW, I am a fan of the metric system, by I could consider switching to miles just to deal with smaller and less intimidating numbers). I could have been waiting for long. Instead, here we are, I received that sign...

The plan. I have 17 weeks. Most of the plans are at least 18 weeks long. Good start. Also, I am not ready to start any plan right away. Hence, this is what I will do:

- I'll spend January increasing the mileage from 20 to 55-60km per week. Mostly easy runs (max 140-145BPM. For those who likes details... My rest HR is 42 when well trained, max HR is 185, LT approx. 165). And a few real workouts (no more than once a week, either intervals or tempo).

- At the end of January, with 12 weeks left, I'll try to follow the Pfitzinge & Douglas training plan. In particular, the baby plan (12 weeks) of the baby plan (max 55 miles).

I am not 100% sure if this will be sufficient to get me there in good marathon fitness. But this is the best I can do with the time given. Fingers crossed!

I was forgetting. Of course you want to know what the target is. Let's be ambitious here: given the performance on shorter races, I could realistically shoot in the range 3:00-3:05, provided that proper marathon training is done. Since I don't have plenty of time, probably this target is a little optimistic. But I'll try in any case: I prefer crashing in trying, rather than being over conservative. Again: fingers crossed!!!    

Finally, I would like to wish good luck to Angela, Hayley and Carlo. But also to all the other brave Eagles that will be running a marathon this spring.

This is were it all began: the Liverpool promenade, where four years ago I did my very first runs...

SAM_1420.JPG