Ideal Care For Proximal Hamstring Tendinopathy By Stuart Butler

The Gold Standard Care For PHT

By Stuart Butler, MSc MCSP Chartered Physiotherapist, Surrey, UK.

 

@physiobutler

 

Stuart Butler, private physiotherapist and Medical Lead at England Athletics has kindly written a blog for the PHT website and community giving his expert opinion on what we should expect from our physiotherapist as patients.

This article is also an excellent guide for physiotherapists.  Knowledge is key with this injury.

 

Fifteen years in track and field athletics, particularly around runners, has taught me a lot about PHTs: their diagnosis and management. This blog is my personal reflection on how I think these should be treated and how to keep runners running. It’s based on my clinical experiences of both positive and negative cases that helped me to learn and develop. It is written from a physio perceptive, but should help those with a PHT to better understand what ideal care should look like.

 

 

Be wary of simple answers because simple answers only answer simple questions and alas PHTs are often not a simple question.

This doesn’t mean that they’re insurmountable injuries that will change someone’s life, but you do have to consider the numerous factors that are involved.

 

 

Key Points:

 

  1. Keep the patient at the centre.
  2. Understand the physiology of what’s going on.
  3. Great (manage) expectations.
  4. There is no perfect prescription.
  5. Select the best available outcomes, assess and reassess.
  6. Don’t over complicate the problem.
  7. Imaging?

 

 

  1. The Person

Everyone who suffers from a PHT is a unique individual, with their own unique set of circumstances, history and goals. Spend time listening to the person, allowing them to tell their story, their understanding of what’s going on, and what they want to get out of physio in order to assist their specific goals. Two people can present with the same injury, but the context may be very different. Many PHT patients suffer with a decreased sitting ability. This would affect a mechanic, who stands for most of his day, differently to an office worker, who sits all day at work, so be aware of the context of the injury for each individual.

 

 

  1. The Diagnosis

The diagnosis of proximal hamstring tendinopathy is complex. We must often exclude other potential diagnosis, whilst understanding that simple things like stress, anxiety, and a lack of sleep can ‘heighten’ the pain response. In my own clinical practice I often describe these as ‘rusty’ tendons. They’re a little thicker and can get in the way, stiff and slow to get going, but often if you build the load progressively they’ll function perfectly for your needs. Be wary of those that don’t quite fit like the hypermobile individual and acknowledge how other conditions may influence the outcome.

 

 

  1. Expectations

Manage expectations of both the therapist and the patient. If we’ve listened well we should be able to set specific goals for the individual, focussed on what they want or need. This may be very different for someone two weeks prior to a marathon versus someone on a couch-to-5km plan. Both are equally as important and we don’t want to stop runners running if possible. We need to design a plan tailored to each individual, empowering them to make decisions on a day to day basis about their ‘load’. I’ll always be honest and say that because these involve tendons, which are stubborn and really slow to let us know somethings going wrong, that to have a positive influence on them we’ll need a minimum of a month (you may see change earlier) and you’ll need to work at this for 3-4 months. The perfect scenario is where the patient has a set of ‘skills’ (exercises / solutions) that they can dip into when they need to.

 

 

  1. Rehabilitation

Many PHT’s are simply a case of doing too much too quickly and acutely increasing the load through the hamstrings. An increase in running volume or intensity, more uphill running or increased sitting on hard surfaces may cause a previously dormant tendon to start causing pain. Often through managing the ‘load’, deloading and then progressively reloading, the symptoms will go away. Physios / physical therapists will often supplement this with some form of exercises. In my own personal practice I tend to use isometric (static) exercises to help with pain and eccentric loading to cause the hamstring tendons to positively adapt, but this always depends on the individual I have in front of me: their needs and goals. Running is an interesting area, and not something I like to take away from someone, so if possible I like to keep people running. It may mean changing sessions and it’s probably best to run alternate days to allow tendons to adapt. Tendons respond to load, and if we take the load away completely (ie: stop running) it can make those rusty tendons a lot stiffer and more painful, so almost all PHT patients need to be loaded on an individually specific plan.

 

 

  1. Outcomes

Make sure you have outcomes. These are ways of showing improvement, because tendons often improve their functionality before they start to feel better or easier. Physiotherapists / Physical Therapists should provide comparative data for each side. I’m a big fan of strength testing. This can be done in numerous formats, from single leg bridges to hand-held dynamometry or isokinetic dynamometry, depending on the patients needs / clinician’s available resources. I use hand-held dynamometry in the clinic, utilising a couple of positions to provide a baseline score / numbers for the patient. It also allows me as the clinician to check that my prescription of the home exercise plan is being effective and to give patients confidence that they’re on the right path. This information will allow me to change or alter the program as and when needed.

 

 

  1. The Problem

I’m a self-confessed hamstring geek, therefore in clinic I tend to see a lot of hamstring injuries. I’m not saying I ‘fix’ all of them, but what saddens me most is when a patient presents with a long and complex history, having had X, Y and Z done to them when fundamental loading issues which haven’t been addressed. I’m not saying X,Y and Z don’t have a place but I see a lot of weakened, apprehensive hamstrings with no clinical outcomes used, that haven’t been loaded appropriately and do really, really well with simple home exercise plans. Marginal gains is a great concept, but please do the 99% else right first before worrying about the 1%.

 

 

  1. Imaging

What can you see? As someone who likes to utilise MSK sonography in clinical practice, we have to be very careful, especially around the proximal hamstrings. It’s a complex area that isn’t well explored in the scientific literature (both ultrasound and MRI), and as with many areas of the body (i.e. low back) we find lots of pathology (abnormal anatomy) in people with no pain or clinical signs. If we perform diagnostic ultrasound we must remember that tendons don’t tend to change their appearance on scans over time. Therefore scans are a useful modality to prove our diagnosis, rather than a monitoring tool for progression.

 

 

Summary:

Proximal Hamstring Tendinopathies are often as complex as the person with them. They are not insurmountable and many people do exceptionally well. Listen to the patient, find shared goals and set good clinical outcomes that can be monitored to show progression. Help to provide context by understanding the causes and empower the patient to appropriately load the tissues. Rehab: Get the basics of loading right, keep running if appropriate, and you should achieve a positive outcome.

 

 

 

 

One Athletes Story Of Injury, Surgery and Recovery

Hannah Erl – Marathon Runner Tells Her Emotional Story of PHT and Surgery by Dr. Lasse Lempainen

Hannah Erl – marathon runner talks about the timeline of her PHT and insertional hamstring tears, the treatments she had prior to surgery, how she decided surgery was the answer, the procedure and the difficult emotional journey along the way that many of us have had.

Hannah’s surgery was performed by Dr. Lasse Lempainen at the Mehilainen Neo Sports Hospital, Turku, Finland. Dr. Lempainen is widely considered the best in his field.

Hann-strings

Treating Proximal Hamstring Tendinopathy Video by Sportsinjuryphysio.com

Treating Proximal Hamstring Tendinopathy – Not Just For Runners

Maryke from Sports Injury Physio talks about why we develop PHT.   Maryke explains the causes and treatments, the effects of some inflammatory diseases, the menopause, relative rest and what exercises to do and why.

 

Proximal Hamstring Tendinopathy: Clinical Aspects of Assessment and Management

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.

https://www.jospt.org/doi/10.2519/jospt.2016.5986

 

 

 

Three Exercises To Avoid With Proximal Hamstring Tendinopathy – Video

Three Exercises To Avoid With PHT Video

 

James Dunn sports injuries rehabilitation expert demonstrates what three exercises to avoid when you have proximal hamstring tendinopathy.  Video 4.15 mins.

 

 

Video of Prof. Jill Cook Talking Tendinopathy Rehabilitation

Professor Jill Cook Explains Concepts in Tendinopathy Rehabilitation

 

A little give away – the changed pathology remains but the tendon grows more good tissue until there is more good tissue than a tendon with normal pathology!  Recently termed the donut effect.

 

Mental Health, Grief and Injury Explained

Why You Feel Grief When Injured And How To Manage These Feelings

Many people say the hardest part of being injured is the impact on their mental health.  On top of that lots of people take up sport to improve their mental health or as a coping mechanism.  Many sporting events are social events. People make friends through sport so when you become injured you feel the losses in many ways.

Maryke Louw of Sports Injury Physio helps you make sense of why you feel grief and how you can help manage these feelings.  Click the link below.

 

https://www.sports-injury-physio.com/post/how-to-deal-with-the-mental-side-of-injury

 

James Dunne’s Complete Guide to PHT

James Dunn, Sports Rehabilitation Specialist, Ex Pro Rugby Player and Marathon Runner’s Complete Guide to PHT

 

PHT Recovery Success Stories

Proximal Hamstring Tendinopathy Recovery Stories

Corina Barbaza Weber’s Recovery

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!

Image may contain: Corina Barbaza Weber, smiling, standing, child, outdoor and text

Mary Bourne-Marth’s Recovery

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)

Image may contain: 2 people, people smiling, people standing

Sam’s Story

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.

Sam

Anonymous

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.

Anonymous
 

Jason Liang Yihao’s Story

Hi all im about to share my road to recovery….

I have PHT 8 mths ago during a sprint and ever since my life changed totally.. i cant do my fav sports which is soccer as soccer would require the hammies all the time. I have done all the eccentrics exercises you name it i have done it and it is useless.

But today i am 90percent to my recovery already 10percent more to go to 100%How to i do it? Im going to share…

2 weeks ago i finally went for my 1st PRP injection (it is pain.. no joke).. after the 3rd day of the injection shockingly i felt the pain has worsen… i was devastated as i do not know what to do if this dont work. I called the clinic and then doc say usually the prp will take effect only on the 3 week n so i just carry on my daily schedule.

As the week progresses the pain became a dull ache instead of a sharp knife pain especially when perform long glute bridge exercise.

After the end of 2nd week of my PRP surprisingly one morning i woke up and find my usual stretch pain drop to 50%. NO JOKE 50%

The next 30% what i did was lots of eccentric exercises. The 2 exercises i felt the best was one legged squad and one legged long glute bridge. I did 3×15 and 3x20sec 2 times per day and it helps alot.

I have now return to running and going for my usual soccer soon. Update you guys again as i might consider going for the 2nd prp shot to solidify the PHT. As soccer playing needs 100%

Good luck guys… Trust me PRP+ eccentric so far has helped me.
You may PM me if you need any help i can share with you more.

Thank you and good luck guys

 

Anonymous

One year ago I injured my hamstring on a short run, trying to increase speed by raising my feet up more. During a long run a couple of days later, I experienced sharp, constant pain in my left glute. I regularly see a chiropractor, who felt it was normal soreness that I could work through. In the meantime, it was painful to sit – any length of time in a chair hurt and cramped my whole thigh. Toilet seats were really rough, as the defined seat seemed to put sharp pressure right against the sorest area, around my left sit-bone.

I knew in my heart this wasn’t something I could just work though and scheduled with a sports-specific PT that had been recommended to me by another athlete. I was diagnosed with high hamstring tendinopathy or PHT. My running got cut back drastically and I had two PT appointments a week to start. These consisted of very small weird movements to address WHY I’d gotten PHT, which was one legs’ dominance, some weaker support muscles, and a hip imbalance. I also got a balance disk to sit on at work which helps keep some pressure off the sit-bone.

I was discharged from PT after six months and was back at half marathon distance without pain. I have PT exercises to do before every run, and my PT person taught me how to detect my imbalance and which exercises I could keep doing from my six months in PT to help address it. One year later, I might feel an occasional brief ache in that area from either sitting too much or after a long run, but it’s fleeting. I have PT exercises I will have to do forever if I want to keep it that way, but it’s worth it.

I wish everyone with PHT the best in their healing, and hope you are able to fully recover.

 

Christine Bridges Back To Running!

Christine’s Recovery

I set out for a run with my running club in September 2018 and within a few minutes I had pain in both buttocks. I carried on run walking but it didn’t ease and I felt very stiff. The pain eased after a few days but I booked in with a physio and she said it sounded like sciatica or piriformis but was unusual as it was both sides in the centre of both bum cheeks. Anyway it seemed ok so I carried on running without any problem but one evening in November I tripped over a manhole cover whilst running. I didn’t fall but stumbled taking me some time to recover and I carried on running back to club. The next day I could barely walk, the pain in my bum was much worse and I couldn’t bend down with bent knees. Again I went to physio but this time a friend of mine (she lives 2 hours away from me) and she was doubtful it was piriformis or sciatica but she gave me a good massage and it seemed a lot better.

Anyway I think at this point I should have told my stubborn self to go to the doctors, but I didn’t. I did a race in December it was going to be 10k but I opted for the 5k. It was bitterly cold and boring and when I finished I could hardly move, my friend wondered what was wrong with me and I thought I was just stiffening up with old age!

Needless to say I carried on running into 2019 and was seeing another physio who thought it was piriformis but odd as it was both sides. In May I drove my friends to a Parkrun an hour away and when I got home I couldn’t get out of the car. I decided then I had to go to my GP, enough was enough. I stopped running.

I was sent for an MRI scan on my spine and referred to a consultant. He said although he could see I had wear and tear on my lower spine this was to be expected at my age, 66, but wasn’t the cause of my pain. He sent me the next day for another MRI on my hips and with this he gave me the diagnosis of Proximel Hamstring Tendinothapy it was the end of July this year. I was referred for physio at the local hospital. Her advice was to do a few stretching exercises and some strengthening exercises. After a couple of weeks she did ultrasound actually on my bum and I could barely walk the next day. Not very helpful.

The problem I also had was that I was going to the USA at the end of September so I needed to endure a 9 hour flight plus a 4 hour drive at the other end. The physio advised that I go for the steroid injections offered by my consultant so I made an appointment. The hospital was 2 hours away and when I got there the consultant, a different one, could not do the injections because he had no scanner to guide him. He advised that I go home a take a course of ibuprofen. No other professional had advised me to take these. I was not happy that I’d driven all that way to be told this but determined to prove him wrong, I took the ibuprofen.

Well after a few days the pain on bending and sitting had eased a bit. I was offered another appointment for the injections one day before my flight and I refused this and carried on taking the ibuprofen. Amazing! That’s all I can say and I know this would not work for everyone but it was total revelation to me! I bought a travel seat cushion for the flight and I had no pain or stiffness at all and I carried on taking the ibuprofen. I thoroughly enjoyed my visit to my son in the USA.

In total I took it for 6 weeks, each time with food and then I started with strengthening exercises. Reducing the ibuprofen too. In November I joined the local gym and signed up with the Personal Trainer who has given me some valuable advice about my running gait and also a strengthening program. I also found a good sports massage guy who has also given me good advice. I started Couch to 5k and I’m now on week 5 and running for 8 minutes!

I have the odd twinge but I can drive for two hours, sit ok and bend to the floor with legs bent. It’s been hard work and I’m taking things very very steady as I don’t want to undo my hard work. I certainly feel much stronger and more toned and will be running back with my club again soon, although not in the dark! I hope this gives hope to those still suffering. X 😊

Image may contain: 1 person, smiling, standing, outdoor and nature
 
 

To talk to people who have recovered, visit the PHT Facebook page:

https://www.facebook.com/ProximalHamstringTendinopathy

 

What Is Proximal Hamstring Tendinopathy…..

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 .