My hamstrings hurts near my butt! – Proximal Hamstrings Tendinopathy

Proximal Hamstrings tendinopathy – the runners hamstring injury

I have written in the past on this blog about hamstrings tendinopathy, an injury common to sprinters and jumping athletes that manifests as pain in the lower part of the hamstring tendon near the knee. We talked here  about the use of eccentric exercise, specifically the nordic hamstrings exercise to treat this problem.

However, not infrequently, runners experience pain not in the lower portion of the hamstrings, but in the upper portion, in the crease of the glutes where the hamstrings originate on the ischial tuberosity, the sitting bones  of your pelvis. This somewhat less common issue is known as Proximal Hamstrings Tendinopathy (PHT).

The exercises we have previously described  can still be helpful in these situations. Sometimes however, traditional exercise management of PHT fails and some new exercise considerations are required.

First of all I want to address what appears to be a bit of a myth in the rehab world around the ‘gold standard’ exercise  for managing tendinopathy. I’ll be the first to admit that I have had a part to play in believing and propagating this myth. Eccentric exercise has long been cited as the go to thing for managing tendinopathies of all stripes, including hamstrings tendinopathies. As mentioned above, the nordic hamstrings drop is often prescribed as a treatment for this brand of tendinopathy and indeed as a preventative measure against hamstrings tendiniopathy – or at least distal hamstrings tendinopathy, the kind that hurts more down by the knee rather than close up at the fold of your butt.

Certainly eccentric exercise works, at least, that’s what the evidence base is telling us so far. However, as a note of caution against drinking the cool aid of one exercise intervention at the expense of all others, is seems that other strength training types can also be effective!

A well designed 2016 study examined the use of eccentric exercise compared with more conventional “Slow Heavy Resistance (SHR)” training for achilles tendinopathies. This SHR training involves both the push and pull (concentric and eccentric) components of a traditional strength training lift. For the hamstrings tendinopathy, relevant exercises might include the deadlift or supine (from laying on your back) bridge exercise. For a more detailed account on how to execute a deadlift download my eBook, “The Foundational Movements” here.

The study found that those who performed SHR training had outcomes similar to those who performed eccentric opnly exercise. And both groups had positive outcomes, that is, improvements in their achilles tendinopathy!

However, in the case of PHT when traditional  exercise interventions as per above fail, a novel, newly proposed exercise intervention, the eccentric treadmill exercise, may be useful. I love this exercise, it’s quirky, a lot like me! You might even be embarrassed to try this one out in your local gym for fear of people looking at you with the old side eye – so naturally it’s right up my alley.

Execute this unique exercise as follows (or you can just watch the video above):

  • Stand facing backward on the treadmill feet on the side bumpers of the machine (not on the belt). Hold on to the rails (please!) on both sides
  • Start the belt moving at 0.8km/hr (0.5MPH) → slow!
  • With the affected side, step onto the moving belt and push backward in an attempt to stop the belt from moving (hint: you won’t be able to!). You should be pushing at “4-6/10” (moderate) intensity. A little bit of pain is ok on this exercise.
  • Let the belt overpower your push until your leg is pushed into hip flexion (bend) such that you cannot maintain contact with your “spot” on the belt without twisting your body. In other words, keep your trunk facing squarely back!
  • Repeat 15 times.
  • Perform 3 sets!

That’s it! Simple and a little awkward to look at!

If you have been unable to treat your PHT with traditional exercise interventions, try this one for 4 weeks and see what the outcomes are. You should expect notable improvements over this time period.

Let us know how it goes!

Further reading (if you really want to impress your friends)

Beyer, R., Kongsgaard, M., Hougs Kjær, B., Øhlenschlæger, T., Kjær, M., & Magnusson, S. P. (2015). Heavy slow resistance versus eccentric training as treatment for Achilles tendinopathy: a randomized controlled trial. The American journal of sports medicine, 43(7), 1704-1711.

Cushman, D., & Rho, M. E. (2015). Conservative treatment of subacute proximal hamstring tendinopathy using eccentric exercises performed with a treadmill: a case report. journal of orthopaedic & sports physical therapy, 45(7), 557-562.

Habets, B., & Cingel, R. E. H. (2015). Eccentric exercise training in chronic mid‐portion Achilles tendinopathy: A systematic review on different protocols. Scandinavian journal of medicine & science in sports, 25(1), 3-15.

van der Horst, N., Smits, D. W., Petersen, J., Goedhart, E. A., & Backx, F. J. (2015). The preventive effect of the Nordic hamstring exercise on hamstring injuries in amateur soccer players: a randomized controlled trial. The American journal of sports medicine, 43(6), 1316-1323.

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