The Most Comprehensive Clinical Paper On Proximal Hamstring Tendinopathy
This clinical paper is written by four of the worlds top tendon specialists: Tom S.H. Goom, Dr. Peter Malliaris, Michael P. Reiman and Craig R Purdam.
This clinical paper is written by four of the worlds top tendon specialists: Tom S.H. Goom, Dr. Peter Malliaris, Michael P. Reiman and Craig R Purdam.
This website is dedicated to proximal hamstring tendinopathy. There’s a link to a global Facebook community where people share their experiences and support each other. You are not alone with this. Talk to people who have successfully recovered from proximal hamstring tendinopathy and returned to running, sitting and a pain free life.
Proximal hamstring tendinopathy is a long name for a group of pathologies where changes have occurred to your proximal hamstring tendons, also known as high hamstring tendons. These changes can either be inflammatory or degenerative and often both. Partial tears are included in PHT.
The hamstring tendons connect the hamstrings to the ischial tuberosity part of the pelvis. PHT causes a deep aching pain just under the glutes, where you sit.
I’ve had this injury for some time and have created this website to share my experiences of PHT.
I’ll be talking about the treatments I’ve had, to help you recover faster and give you support along the way.
The road to recovery can be frustrating and testing to say the least. It can take anything up to 2 years to recover.
Although we could all do without pain, the position of this particular tendinopathy can restrict your daily activities, especially sitting and bending. It’s thought of as a runners injury but certainly isn’t exclusive to running.
Sitting, stretching and running tend to aggravate the tendons making them more painful.
Generally, this injury comes on slowly, presenting as mild pain at the top of the posterior thigh. So good news – there’s an early warning to take action.
Sometimes, PHT can also be caused by a sudden acute injury.
If you’re feeling at your wits end, this can be fixed.
To connect with people with PHT, to find answers, feel supported and read recovery stories, visit the PHT Facebook page here .
Your upper body weight pushes through your hamstring tendons. However, your semimembranosus hamstring tendon is copping most of the pressure due to it’s position.
There’s three tendon parts attaching the three hamstring muscles to the ischial tuberosity (area of the pelvis).
My semimembranosus tendons (my case was bi-lateral) were the affected parts. I had a paperless desk job. So no reason to get up and walk about. 10 Hours of sitting a day plus driving to and from work equalled 12 hours of sitting.
After 3 months of the paperless job, my proximal hamstring tendons were a 7 – 8/10 on the VAS scale and I could hardly sit. I continued to drive to work for another 6 months and stood at my desk all day.
Standing for long periods of time is not a good idea. Too much of any activity will put a strain on groups of muscles and tendons, potentially causing more injuries.
I asked for a better chair and an up down desk which wasn’t forthcoming so had no option but to go off sick as I was unable to continue.
The next two years were spent standing as I could no longer sit down at all and having exhausted treatments available in the UK, after hours and hours of research, I flew to Finland and had a bi-lateral proximal hamstring tenotomy.
Don’t despair, most people recover before surgery becomes an option. Surgery is the absolute last resort.
My surgery was successful. Just a side note, Finland is a wonderful country and so too it’s people. We had a great time and want to go back and see some more of it.
However, my re-hab at home was not so good so I’m still recovering…. forever hopeful.
Sit on a thick spongy, pillow or cushion. Carry this about with you. Take it to work and use it for driving. Heads-up here, obviously it puts you in a different driving position so take it easy to start with. Take time to adjust.
You can buy a cushion/seat pad on Amazon designed for PHT. There’s holes cut out for the sit bones (ischial tuberosities). However, people have said it’s chance if the holes line up in the right position for your bone structure and it’s quite pricey. On the flip side, others have found it helped with their recovery and rated it highly.
As an alternative, people buy gardening kneeling cushions, measure up and cut their own holes. This apparently has worked very well and is a cheaper option.
Another pain reliever is the Wondergel seat pad. Community member recommeded:
Don’t sit for longer than 15 – 20 mins without getting up and walking about. This takes practice, especially at work. You get into what you’re doing and before you realise, an hour or more has gone by.
Standing takes the pressure off your tendons, allowing blood through and walking about causes the blood to flow quicker, taking oxygen and nutrients to the injured area and toxins away. However, standing all day isn’t good for you either so mix sitting, standing and walking about if you can.
Ask for or purchase an up/down desk.
This one has been recommended by a member of the Facebook PHT community:
Price £79.99 UK
If you want something ergonomic, portable and are concerned about the environment, try these natural products made by carpenters and cabinet makers and sold by Deskstand, Cape Town. This company also comes recommended by a PHT member so tried and tested!
I noticed an improvement in the quality of my tendons after using a pillow. They felt less ropy so these measures can help with recovery.
I also used a simple pacing and grading Word table after I hadn’t sat for two years. If you don’t sit on your tendons, they become deconditioned. So I started at 30 seconds on a soft surface, then a minute and increased the time every two days by 30 seconds, until I reached 10 minutes. Then I went up by a minute every two days and brought in a slightly harder surface alongside starting at 30 seconds with that. If you don’t want this hassle, don’t stop sitting completely.
Keep your water levels up and don’t skip meals…. more reasons to get up.
Talk to other people with PHT to understand how they manage sitting: https://www.facebook.com/ProximalHamstringTendinopathy
Hope this helps with improving your pain levels and your recovery.
This directory was created following a request from a PHT community member.
Every clinician listed has been recommended by a PHT community member who’s received treatment from that clinician. The only criteria for the directory is a PHT community member recommends them.
The directory is designed as a starting place and in no way takes the place of you researching who to see before you see them. The author takes no responsibility for other’s decisions and their outcomes.
To manage proximal hamstring tendinopathy, start by cutting back on the activity that’s aggravating your tendon. It’s thought, tendinopathy (tendinosis) is partly an overuse injury. The tendon cannot keep up with the amount of activity and the repair process so degenerates.
Tight, weak hamstring muscles cause pulling on tendons and restrict blood flow which causes degeneration.
Weak glutes are another factor. Glutes should be powerful to propel you along. If your glutes are weak, the hamstrings take over and they aren’t designed for this type of work.
Have a full examination of the kinetic chain by a qualified, registered physiotherapist. If you have access to an MRI, have this done early on. This should rule out other injuries.
Once you have confirmation of your diagnosis, your physiotherapist can prescribe an eccentric strengthening exercise programme. A good physio will advise you on how much of what type of activity is right for you .
Everyone’s PHT is different. Different stages of severity and recovery. The programme and advice should be tailored to you.
The treatment that produces results, is an eccentric strengthening programme.
Tom Goom of The Physio Rooms and creator of RunningPhysio.com describes the onset of his proximal hamstring tendinopathy. Tom also talks about his gradual loading programme here. www.running-physio.com/pht-rehab
Prolotherapy involves injecting a natural solution directly into the injury site to cause an inflammatory reaction. This is to create new healthy tissue, strengthening the tendon.
From what people have reported, the best results come from having lots of areas of the tendon injected instead of the solution going into one place.
PRP (platelet rich plasma) is a form of prolotherapy. Platelet rich plasma, from the same patient, is injected into the tendon to promote healing.
Printed in Muscles, Ligaments and Tendons Journal.
Platelet Rich Plasma Treatment Improves Outcomes for Chronic Proximal Hamstring Injuries in an Athletic Population. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4327356/
Dry needling (IMS – intramuscular stimulation) is inserting dry needles (not injecting anything) into shortened, tight muscles and tendons to create micro tears. This induces the bodies’ inflammatory reaction and repair process. Also, when needles are inserted, trigger points (knots) cramp around the needle. When the needle is removed, the trigger point relaxes.
IMS was developed by Dr. Chan Gunn. Find out more here: http://www.istop.org/
Steroid injections are generally considered not worthwhile. If you are lucky, you get approximately six weeks of pain relief but an extended period of recovery time. It’s also thought steroid injections are deleterious to tendons.
If you and your doctor decide steroid injections are appropriate, make sure it’s ultrasound guided. The injection should NOT go into the tendon but should go into the tendon sheath space around the tendon.
ESWT (Shockwave therapy) breaks up calcification within tendons. It also causes micro tears that the body repairs. This generates new tissue and reduces inflammation. Although it is somewhat painful, it is tolerable for the short period of time it’s administered. Do not have more than six sessions.
The practitioner should use different heads depending on the anatomy he/she is working on and adjust the intensity during treatment.
The protocol for shockwave therapy is six sessions. It seems healthcare professionals give three sessions, one a week for three consecutive weeks. The patient then has a break for a month to see how they improve while following an eccentric exercise programme.
The Biological Effects of ESWT on Tendons, The Muscles, Ligaments and Tendons Journal. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3666498/
If all else fails and the effects of PHT are too great on your day to day life, surgery can be an option as a last resort. I had a bi-lateral proximal hamstring tenotomy after having PHT for five years. There are different types of surgery for this condition.
One third of my semimembranosus tendon was cut off my pelvis and stitched lower down to the bicep femoris tendon. This lengthened my hamstrings by 3.5cm.
I was given a gradual eccentric strengthening exercise programme to do at the appropriate time following surgery.
I also had a build-up of scar tissue cut away.
However, I wish I’d had my bloods done when my PHT first appeared. Having a mineral profile done may save a lot of hassle and money in the long run.
Nutritional deficiencies and imbalances can be the cause of tight muscles and tendons.
Plasma and RBC blood tests give a more in-depth picture than serum whole blood tests. See the nutrition for PHT post: https://proximalhamstringtendinopathy.org/nutritionforpht
Plasma and RBC mineral profile blood testing may find the underlying cause of your PHT.
If you’re taking supplements without blood testing, they may be causing a nutritional imbalance. This imbalance can cause tight and weak muscles that pull on your tendons.
You can check the registration of a physiotherapist here: http://www.hpc-uk.org/check/
As stated on this site’s home page, I’m not medically qualified in any way, I’m merely a patient with long-term experience of PHT and it’s treatments. All decisions you make, are entirely your own. Always seek professional advice.
If you’ve tried most treatments for proximal hamstring tendinopathy and there’s nothing else left that sounds sane, it could be your nutrition blocking your recovery. Nutrition is fundamental to tendon repair.
If you think you are low or deficient, consider blood testing.
Red blood cell and plasma blood tests show what’s happening inside your cells and serum whole blood tests show what’s happening outside your cells, in your whole blood, as it says.
Symptoms of deficiencies include muscle tics, tight muscles, numbness, tingling, headaches, insomnia, fatigue, muscle weakness, hair loss, dry scaly skin, palpitations and more.
It’s not ideal to pop into your local high street health food shop and pick something up, as a stab in the dark, to fix a health problem without blood testing first. There’s a lot of great advice on the internet but using it to work out if you are low on something and trying to fix it yourself, without testing, may cause nutritional imbalances.
For example, magnesium and calcium work together to relax and contract muscles. If you are low in magnesium and top heavy in calcium, your muscles contract causing pulling on your tendons.
Excess vitamin C is eliminated by the body by attaching itself to another mineral which is excreted, resulting in mineral loss.
Whatever supplements you take, they will deplete or impede something else and so it goes on. Plus there are only so many binding sites and if there’s nowhere to bind to, the vitamin or mineral is lost.
If blood testing shows a deficiency, talk to your doctor first before taking supplements and take them temporarily, until blood tests show your levels are optimum, then stop when your doctor advises.
I still see posters on the London Underground advertising multi vitamins with a famous actor (in his 40’s) saying he’s been on them since his twenties.
Low or deficient vitamin D also impacts your musculoskeletal system. Here’s what the UK Government have to say about it via the NHS.
“The government says it has issued new vitamin D recommendations “to ensure that the majority of the UK population has satisfactory vitamin D blood levels throughout the year, in order to protect musculoskeletal health”.
Read the full advice from the NHS using UK government guidelines here: www.nhs.uk/news/food-and-diet/the-new-guidelines-on-vitamin-d-what-you-need-to-know
Obviously, this applies to the geographical position of the UK but gives a good indication on how important vitamin D is for everyone’s musculoskeletal health.
When you’ve a long history of tendon injury and nothing seems to fix it, you put a lot of energy into considering ways you can. Ways you can get back to living your life pre PHT.
Collagen supplements are one of the more easily obtained potential treatments for PHT or any musculoskeletal injury. There’s been a lot of interest in these over the last few years and you can see why. Pop into a health food shop on the high street, pick some up for a few pounds and start taking them that day. Far more accessible than waiting for a medical appointment, scans, follow-up and a lot cheaper if you don’t have access to a state run health service. You feel like your doing something positive towards your recovery. You sometimes pin your hopes on them. So are they worthwhile and what does the research say?
Most collagen studies have been of small sample groups and industry funded so the question to ask is can you trust an industry funded study? Nearly all existing research has focused on supplements and not food so can you get the same collagen production from a healthy balanced diet? Libby Mills – Spokesperson for The Academy of Nutrition and Dietetics, Chicago and Washington says “Maybe if people consumed adequate protein, they would get the same benefit.” The body breaks down both food and collagen supplements into amino acids in the same way to produce collagen. Libby Mills talks about collagen supplements verses food sources in Jamie Santa Cruz’s article for Today’s Dietitian Magazine, March 2019. https://www.todaysdietitian.com/newarchives/0319p26.shtml
Apart from collagen (a protein found in meat, fish, eggs, dairy and spirulina) vitamin C is the main co-factor in collagen synthesis. Vitamin C is also an antioxidant which helps reduce oxidative stresses that degrade collagen. The outcome of a study for the use of vitamin c, following musculoskeletal injuries, was favourable. The study appeared in The Orthopaedic Journal of Sport, Oct 2018 titled “The Efficiency of Vitamin C Supplementation on Collagen Synthesis and Oxidative Stress After Musculoskeletal Injury.” https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6204628/
Libby Mills says “Zinc and sulphur are also co-factors in collagen production.” Vitamin A is also involved and an antioxidant. This article, written by Jamie Santa Cruz, in Today’s Dietitian Magazine, states what to eat to get all you need. https://www.todaysdietitian.com/newarchives/0319p26.shtml
One of the world’s favourites – sugar! “Sugar molecules bind to collagen fibres which results in the formation of advanced glycation end products.” Writes Jamie Santa Cruz. Patricia Ferris MD, Clinical Associate Professor of Dermatology at Tulane University School of Medicine says “These bindings cause an irreversible loss of strength and flexibility in collagen fibres.” As well as sugar’s impact on collagen synthesis, alcohol inhibits the absorption of vitamins and minerals impeding collagen production while smoking causes irregular fibril organisation and fibroblast degeneration in tendons. Read about cigarette smoking and the effects on tendons here: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3711704/
Although these small studies have had good results supporting collagen supplementation, Libby Mills makes a valid point “Spending money on supplements doesn’t seem to be necessary because there are many food sources and if you are eating a balanced diet, you should have the nutrients you need.” So perhaps an improved diet and lifestyle is all it takes while we wait for larger non industry funded studies.
About Dr. Alison Grimaldi
Exert from Dr. Alison Grimaldi’s Website
With 25 years of clinical experience and particular expertise in the management of hip, groin and lumbo-pelvic pain and dysfunction, Alison is Principal Physiotherapist at Physiotec and an Adjunct Research Fellow at the University of Queensland. Alison also has a special interest in the assessment and optimisation of lumbo-pelvic and lower limb biomechanics for running, change of direction and all weightbearing sports, aiming to maximize an athlete’s performance outcomes and minimize risks of injury or re-injury.
Dr. Alison Grimaldi’s ebook series:
Tendinopathies of the hip and pelvis represent a large burden on both the sporting and ageing populations. Growing evidence is shaping contemporary conservative management of tendinopathy.
This e-book series aims to provide readers with guidance towards a deeper understanding of tendinopathies of the hip and pelvis and more effective clinical management based on an emerging evidence base derived from scientific studies on structure and mechanobiological mechanisms, risk factors, impairments and the available information on effects of intervention.
Link to her recently published books including book 3 Proximal Hamstring Tendinopathy:
All information on Proximalhamstringtendinopathy.org is based on the experience of the author who suffers from PHT and is not provided by a qualified medical professional.
The information is intended to motivate readers to make their own health decisions after consulting with their health care professional. The author is not medically qualified and takes no responsibility for others decisions about their health.
The information on this website is not intended to replace a one to one relationship with a qualified health care professional and is not intended as medical advice.
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