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Hamstring Pain – April Newsletter

Proximal Hamstring Tendinopathy:
A literal pain in the butt

Holly Warner, DPT

Proximal/High hamstring tendinopathy is literally a pain in the butt. Symptoms are characterized as deep gluteal pain that is localized at the ischial tuberosity (sit bones) and can radiate down the posterior thigh/hamstring 1,2. It is fairly common for distance runners to experience this type of injury sometime during their training. Like most tendinopathy symptoms are often worse at the start of a run, but then warm-up as the run goes on and again return or worsen afterward1,3. Pain is often worse with prolonged sitting, driving, and running and often become chronic.1,3

diagram of the hamstringIt is characterized as an insertional tendinopathy due to the injury occurring at the site of its bony attachment. Insertional tendon injuries often occur with high compressive loads which cause the tendon to be compressed at its bony attachment. Compressive loads are highest when the hip is flexed and adducted as this wraps the tendon around its attachment at the sit bone. During running it is at late swing phase that the hamstring is working the hardest and the tendon is most vulnerable to compression.1 Other activities that increase compressive hamstring tendon loading include speed work, uphill workouts, lunging/squatting with weight, and aggressive hamstring stretching.1
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Several factors that may contribute to increased hamstring tendon irritation and prolong healing time in runners include:1,2

  1. Over-striding
  2. Excessive forward trunk lean
  3. Training errors including continued speed training and hilly workouts when in pain
  4. Aggressive hamstring stretching
  5. Increased anterior pelvic tilt
  6. Tight hip flexors
  7. Poor core stability/abdominal muscle weakness

Eliminating aggravating factors is the first step to treating high hamstring tendinopathy. The next step is loading the tendon appropriately. Tendons despite not liking compressive loads, do in fact need to be mechanically loaded to improve tensile strength in order to heal and repair. Therefore, initial loading includes hamstring strengthening with the hip in a neutral alignment. One of the easiest exercises to begin with is bridging.

Bridging progressions include double leg glut bridging, progressing to hamstring bridging, and then to single leg bridging. Working on hip flexor stretching and trunk stabilization exercises are also important in this stage.1 Exercises to improve trunk stability include forward and side planking, hands and knee leg and arm extension (bird dogs), lower abdominal marching (see photos).

Low load exercises as mentioned above are a great place to start. Though, it is important to seek medical guidance in order to progress the strengthening program appropriately. Hamstring strength deficits along with gluteus medius and maximus strength deficits are often key contributors to injury recurrence.1,2 Therefore, it is important to learn from a skilled provider how to effectively load these muscles gradually in order to build strength without irritating the tendon again.

John Fiore running in a beautiful green landscape with waterfall A movement assessment is also critical in management of high hamstring tendinopathy. At Sapphire Physical Therapy we use a 2D video running gait analysis system to look more closely at running mechanics. The ability to slowdown the video and analyze the gait cycle allows us to catch things like over-striding and excessive anterior pelvic tilt which may be hindering the healing process and contributing to continued pain. Please feel free to email or call us or visit us at The Runner’s Edge every 1st and 3rd Thursday of the month for a free injury consult.

All photos below are from hep2go.com

diagram for hamstring exercises diagram for hamstring exercises diagram for hamstring exercises


Muscle of the Month: Lumbar Multifidus

Jesse Dupre, DPT
The multifidus is a muscle comprised of multiple bundles or fascicles of muscle fibers that are located just lateral to the spine on both sides and deep to the more prominent superficial spinal muscles. While present throughout the spine, the multifidus is particularly important in the lumbar spine, and its function and relationship to low back pain has been widely studied. The fascicles of the multifidus span 2-4 spinal levels, and directly connect two vertebrae via muscular attachment.
Although the multifidus is comprised of multiple muscular bundles (fascicles), it is considered one muscle, and it spans the entire spine from the C2 vertebra to the sacrum.
In the lumbar spine, each portion of the multifidus originates just lateral to the spinal canal at the lower vertebra and attaches centrally at the spinous process of the upper vertebra. In the lumbar spine, the multifidus is effective at extending the spine during backward bending, as well as rotating the lumbar spine. Additionally, it serves an important role in stabilization.

The location and orientation of the multifidus make it an effective stabilizer of the spine. Because it is close to the spine itself and each section spans relatively few segments, it does not exert the same shearing force on the spine as the larger, powerful erector spinae group, and provides more localized stability than the superficial spinal muscles. The multifidus is well suited fine tuning of movement and postural support due to a high density of muscle spindles, which provide information about movement to the nervous system.

Diagram of support muscles of the lumbar spine
In research studies, decreased size and strength of the lumbar muscles, particularly the multifidus has been associated with low back pain. It is, however, possible to strengthen the multifidus, as well as the rest of the lumbar muscles for individuals with, or without low back pain. There are many exercises that can be used to strengthen the low back as a whole, and it is possible to preferentially strengthen the multifidus over other lumbar muscles. An example of a great exercise to specifically target the multifidus is the bird dog.


1Goom TSH, Malliaras P, Reiman MP, Purdam CR. Proximal Hamstring Tendinopathy: clinical aspects of assessment and management. Journal of Orthopedic and Sports Physical Therapy. April 2016.
2Chu SK, Rho ME. Hamstring Injuries in the Athlete: Diagnosis, Treatment, and Return to Play. Current Sports Medicine Reports. 2017;15(3):184-190.
3Beatty NR, Felix I, Hettler J, Moley PJ, Wyss JF. Rehabilitation and Prevention of Proximal Hamstring Tendinopathy. American College of Sports Medicine. 2017;16(3):162-171.

References for Muscle of the Month:
Goubert D, Oosterwijck JV, Meeus M, Danneels L. Structural Changes of Lumbar Muscles in Non-specific Low Back Pain: A Systematic Review. Pain Physician. 2016 Sep-Oct;19(7):E985-E1000.
Ranger TA, Cicuttini FM, Jensen TS, Peiris WL, Hussain SM, Fairley J, Urquhart DM. Are the size and composition of the paraspinal muscles associated with low back pain? A systematic review. Spine J. 2017 Nov;17(11):1729-1748. doi: 10.1016/j.spinee.2017.07.002. Epub 2017 Jul 26.
Fortin M, Macedo LG. Multifidus and paraspinal muscle group cross-sectional areas of patients with low back pain and control patients: systematic review with a focus on blinding. Phys Ther. 2013 Jul;93(7):873-88. doi: 10.2522/ptj.20120457. Epub 2013 Mar 15.
Kliziene I, Sipaviciene S, Klizas S, Imbrasiene D. Effects of core stability exercises on multifidus muscles in healthy women and women with chronic low-back pain. J Back Musculoskelet Rehabil. 2015;28(4):841-7. doi: 10.3233/BMR-150596.`