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 .
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.
After fighting for almost one year PHT, just completed now a pain free, injury free half marathon in 1h37min, beating my 2016 PB. For everyone out there who is exasperated of not being able to sit without pain, let alone bend forward or run, I tell you: don’t lose hope. Stay focused, wrap yourselves in KT tape and don’t miss your boring Physio, massages and gym sessions with eccentric hamstring exercise and planks. God bless you and give you the strength to fight until you’ll get healed!
After 2 years of fighting, PT + dry needling + lots and lots of support from friends and family led me back to race running – this is the 10k Blue Bell fun run in Brenham, TX. Please don’t give up. Get a good Ortho and good PT (if there is anyone out there in Houston, I have recommendations for both after suffering through several bad experiences). I have been running 7 miles every Saturday with my buddies, riding horses again, and sitting through Broadway plays and movies with the help of a special pillow. I am not 100%, but at least 90% healed. Hang in there, I am cheering for all of you! (especially Vicki)
Almost 5 years ago I started to develop HHT. It started appearing while running, during a football pre-season. A sort of tugging feeling. I’ve never had a muscle/tendon injury before so I just assumed I’d run through it and it would get better.
It slowly got worse through tennis and football and before I knew it, I could barely kick off my shoe.
Over the next two years, I went to two chiropractors, one physio, one sports doctor and a deep tissue massage therapist.
Nothing seemed to work.
I just thought it would get better but I would always do something to hurt it …… like running or kicking without warming up etc.
The annoying thing about my injury, was if you did injure it further, you couldn’t feel the result until at least 1 – 2 days later.
I ended up going to another physio over a year ago. She recommended I started resistance training on my hamstrings and build up my glutes.
Slowly, I built up the strength in my hammy and was able to run at footy.
I had a lot of set-backs and had to restart again if I pushed it too hard running or kicking, if I didn’t warm up properly or did too much weight with exercises.
It’s been about a year now, I’ve been at 100% with sport. I still have to be smart and warm up but it’s good.
The key thing for me were:
Don’t do static stretches.
Do some dynamic stretches.
Glute and hamstring resistance training.
A good warm up before sport.
This is not an injury that can be fixed with rest. You must work at it using paced and graded exercises.
Most importantly, you gotta know your limits, don’t push too far because it might set you back.
I’d suffered with HHT for about 12 months (49 yrs old with a marathon / ultra marathon running background) and then thought I had gotten over it but had a really bad set back (after a 50km training run) that saw it flare up for another 4 months.
Have been 99% pain free for about 6 months now and have completed the Tokyo marathon and 2 x 100km trail races pain free during this time. Clams and more clams (daily) seemed to really help me along with continuing to load the tendon up to a tolerable point but being cautious not to over do it. I never really stopped running, but my speed definitely suffered.
By far the worst injury I’ve ever had, and I still feel like I’m not absolutely over it, despite how good the hammy feels. I’ve learned the pain signs that tell me when to back off, and also how important it is to keep exercising, keep running and avoid stretching and icing (at least for me). Good luck to everyone and definitely hang in, there is light at the end of a long tunnel.
To talk to people who have recovered, visit the PHT Facebook page:
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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