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).


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... :|


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").


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...