Understanding Proximal Hamstring Tendinopathy

: on today's episode, Understanding Proximal Hamstring Tendonopathy. Welcome to the podcast helping you overcome your proximal hamstring tendonopathy. This podcast is designed to help you understand this condition, learn the most effective evidence-based treatments and of course, bust the widespread misconceptions. My name is Brodie Sharp. I'm an online physiotherapist, recreational athlete. creator of the Run Smarter series and a chronic proximal hamstring tendinopathy battler. Whether you are an athlete or not, this podcast will educate and empower you in taking the right steps to overcome this horrible condition. So let's give you the right knowledge along with practical takeaways in today's lesson. Let's dive into episode two. We're diving into proximal hamstring tendinopathy insights. Welcome back. I hope you enjoyed episode one. Hopefully you got a lot of takeaways from that and a lot of understanding. If you haven't listened to it, if you've just checked the episode titles and been like, oh, let's just dive straight into this one, please do not do that. Please go back to episode one because those basics that you need to understand, I'm just gonna skip over here. So you. If you need to know more about an understanding around tendinopathy specifically, then please go to episode one. So let's dive straight in. What is proximal hamstring tendinopathy? Let's start with the anatomy. So your hamstring muscles become tendon and then attach onto your ischial tuberosity, which is your sitting bone. So when you sit down, particularly on a hard surface, and you can feel your sitting bones compress on the... bench or seat wherever you're sitting, that's exactly where those hamstring tendons attach onto. And the location of a tendon pathology can vary. And there was some studies, Benozo et al in 2013 found that there was a considerable amount of variability, found that in the common hamstring tendon, there was all like out of all the people that had proximal hamstring tendinopathy, 23 of them, 23% of them resided within the common hamstring tendon, 41% resided in the biceps femoris, 29% in the semi membranosis and then 6% in the semi tendinosis. And so those are the three muscles that make up your hamstring. You can, I wish I had some Google images or something to show you but audio format. That's why sometimes the proximal hamstring course is a good option to have a good visual. But we need to consider this pathology as an insertion or tendinopathy. And so things like compression of the tendon become a big factor, particularly hip flexion and... sometimes hip flexion with adduction. So an insertional tendinopathy is a part of the tendon pathology where it's right as it attaches onto a detachment point. Sometimes there might be a mid-portion tendinopathy, say for your Achilles, the tendon that becomes quite sore is smack bang in the middle of the tendon itself, not where it attaches. And you know, most people who find that they have sore Achilles, they'll point halfway up there, halfway up the tendon. And so when we're dealing with an insertional tendinopathy like this proximal hamstring, we really need to factor in compression and make sure if it's not tolerating a lot of compression, then we have to take the tendon out of compression and try and avoid those irritations or those postures that might lead to a flare up or lead to an increase in symptoms. So that's a bit about the anatomy. What actually causes it? Yes, we did talk about this last episode, mainly around like the compression, the tensile factors. So speed would be an interesting factor that could. increase the demand of the tendon. So it's like if we were to say if you're a runner and you decide to run at a certain speed and then your next run you decide to run considerably faster, the demands of the tendons muscles joints throughout your body increases significantly. And so that's what we're talking about when we're looking at tensile load, compression, overloading compression. We've delved into a little bit already, but specifically around the hamstring and specifically around running. If you were to imagine during the swing phase, so when a runner is planting one foot on the ground and their other leg is swinging in space, their knee is quite bent. I'm just like doing this as I'm talking through it. So as the knee is bent and the leg is swinging through, what happens is when you get to, the second phase of that swing phase, the knee starts to straighten out and the leg starts to straighten out. And the leg is close to straight by the time it hits the ground in what we call a terminal swing phase. And while that leg is straightening out, what the hamstring is doing is contracting to help slow down the rate of what your foot is doing. We can't just quickly rotate the leg over. It needs to be it needs to decelerate, it needs to slow down before the heel is getting placed on the ground. And so the hamstring contracts in order to do that, but it also lengthens while it is contracting. So we call that eccentric, an eccentric contraction. And so when we're looking at a runner that increases their speeds, the hamstring itself needs to work really hard because the legs are ticking over quite quickly. in order for the hamstring to successfully slow down the momentum and slow down the speed of that foot before it touches the ground. This we need to consider when it comes to, yes, running speeds, but also fast walking, also hiking. If you want to say, oh, I can't run, but let me just walk and see what I can do. Walking speeds can start to irritate the tendon if it's beyond your capacity. So keep that in mind. So that's the tensile component. If we're looking at the compression component, we're looking at things like, let's say running hill because you need to place your foot up higher and so that puts your hip in more flexion. So if you were to stand up tall and bring your knee towards your chest that's what we call hip flexion and the more your hip goes into flexion and you push off the ground the more compression that tendon will have. So keep that in mind running uphill cycling I've mentioned last episode cycling in like more of a aero position where people have really tucked and bent really that puts that hamstring tendon under more tension or compression. Other examples I can think of would be like a rowing machine. If you're at the gym and you go into that row position, as soon as you push with your feet, when your knees are essentially almost tucked to your chest, that is a lot of compression and sitting, we know sitting causes compression of the tendons. That is almost direct. direct pressure because we're in hip flexion, yes we are, but it's almost like the surface is contributing to the pressure. Whereas I guess the bike seat and I guess the sitting in the rower does that as well, but just things to keep in mind. Symptoms per se, so it's usually felt as like a deep kind of localized pain in the region of the sitting bones that issue tuberosity. It often gets worse after bouts of activity, usually running, lunging, squatting, sitting. We need to make sure that the symptoms themselves, sometimes they become less symptomatic. They have what we call this warm up effect. So your first couple of minutes of cycling might be... quite sore, you might feel it, but as the legs warm up, as the tendon warms up, symptoms tend to go away. That's a characteristic of a tendon pain, especially in the early days. So keep that in mind, it's localized to the sitting bones and it has that warm up effect. We're going to delve into some tests and some potential differential diagnoses and some risk factors in a second, but we're just going to chuck in an ad and we'll be right back. This podcast episode is sponsored by the Run Smarter Physiotherapy Clinic, which is my own physio clinic where I help treat a wide range of PHT sufferers, both locally in person and all over the world with online physiotherapy packages. In the years I've been self-employed as a physio, close to 70% of my entire caseload has been helping people with proximal hamstring tendinopathy, which is why I decided to launch this podcast. So if you're building upon your own rehab knowledge through the podcast, but still require tailored assistance, I'd love to be on your rehab team. Whether you are a runner or not, head to runsmarter.online to see your available options for working together. If you're still unsure if physiotherapy is right for you, or if you need a rehab second opinion, you can always schedule a free 20 minute injury chat with me. Find the free injury chat button on my website or in the podcast show notes. to be taken to my online calendar to book in a time. Okay, there are some tests that you can do. There might be some, like just some movements that you can do at home, just to see if it's really getting to that hamstring area. I don't necessarily want you to diagnose this yourself, but there are some things you can do. One of the main things that I use in clinics is what we call the show off test. And if you're standing, and you've got your shoes on and you bring your heel to the front of the other foot and try and scrape your shoe off. You know sometimes people kick off their shoes like that they dig their heel into the toes of their other foot. If that triggers some pain... into that area if you feel like a sharp sensation or it triggers your symptoms high in that buttock area where those sitting bones are, we can start to think that maybe this is a hamstring tendinopathy. The other test which is quite similar is you can stand close to a wall with your back to the wall and then you just take that symptomatic leg, float it in the air and then try and press your heel back into that wall. If that triggers some symptoms then... it's starting to increase the likelihood of it being that particular proximal hamstring tendinopathy. Other things that might aggravate the pain would be like an arabesque, a deadlift, anything that's really compressing that area or really asking high demand of that tendon, particularly under compression or under tension and isolated to that area. a differential diagnosis. I'll refer to Tom Goom. He had a paper in 2016 and he did say that the more diffuse the symptoms, it may start to increase the likelihood of back involvement, so the lumbar spine, hip involvement, the sacroiliac joint, maybe referral from a disc or like a what we call a radiculopathy, some sort of nerve involvement, a sciatic nerve involvement as well, as it's very close in relation to that hamstring tendon. So if things start to become more diffuse, if symptoms start to become more widespread, say into the hip or further down the leg, we're not necessarily looking at just. proximal hamstring tendinopathy, it could be both or it could be something completely different, which is why I recommend you get it assessed and diagnosed by a health professional that's really proficient in seeing these particular conditions. So let's dive into risk factors and risk factors. I've already discussed a little bit in last episode, but I'll add in here again, talking or referencing Tom Goom and his paper in 2016. suggested that there are symptoms that may be due to excessive static stretching. For example, if you're just started doing some more yoga or doing some more Pilates postures or if you're a teacher studying to be a Pilates teacher and you're doing a lot of stretches. particularly the one where you're sitting, legs out straight in front of you and you're reaching forward to touch your toes. That puts the hamstring tendon under a lot of tension and can potentially trigger some sort of pathology if it's not used to that level of compression. So keep that in mind. All the other risk factors were last episode. Don't need to repeat myself again, but. when we're talking about the proximal hamstring tendon, these are some risk factors that you might need to be aware of, especially in the future if you don't wanna flare things up. So a bit of a recap, when we talk about the anatomy, yes, all those tendons, the hamstring tendons, attach onto that sitting bone. It's considered to be an insertional tendinopathy, so the pathology of the tendon as it attaches onto its bone. So we need to really be careful of compression as well as that tensile load. The hamstring tendon works really hard with things like increasing your walking speeds and increasing your running speeds and then just putting yourself in more of a compression position, so like tucked forward or more of that hip flexion. Keep that in mind. Symptoms are really localized to the sitting bone. If it starts to become quite widespread, then we're looking at either a diagnosis, a totally different diagnosis or something that's concurrent with your proximal hamstring tendinopathy. So keep that in mind. The tendon does... tend to have a warm up effect, especially in the early days of pathology. So if it's, if you're exercising for a couple of minutes, those symptoms can go away, but then return definitely like later on the day or the next morning. We talked about some tests that you can do and we talked about the potential like risk factors. And so that's it for today. Hopefully this is helping your understanding. Hopefully all of these bits of information and making a whole lot of sense to you and what you are experiencing. Stay tuned next time we're going to talk about the tendon rehab. and prevention from another one of my past Run Smarter podcast episodes. So look forward to bringing you that and we'll catch you next time. Thanks once again for listening and taking control of your rehab. If you are a runner and love learning through the podcast format, then go ahead and check out the Run Smarter podcast hosted by me. I'll include the link along with all the other links mentioned today in the show notes. So open up your device, click on the show for you. Congratulations on paving your way forward towards an empowering, pain-free future and remember, knowledge is power.