Hamstring Tendinopathy – A real pain in the…

The Trouble with Hamstrings


I see a lot of people who tell me they’ve ‘pulled a hamstring’ – it’s a common enough condition – and in most cases they’ve self-diagnosed accurately. But beware, that pain may not be all it seems.

There is another condition called Hamstring tendinopathy which may feel similar, but clinically is a very different problem. In order to apply the most suitable management strategy, it’s important to get an early, accurate diagnosis.

Hamstring tendinopathy can often be difficult to rehabilitate with frustrating, long-term interruptions to your training and day to day activities. So early diagnosis and appropriate treatment are critical factors in getting back to full fitness.

In the next couple of days I’ll also release a blog discussing hamstring strains (a.k.a. pulled or torn hamstring) to help you understand the underlying differences in these conditions.

A little anatomy lesson

Here’s a brief insight into hamstring anatomy. We all know hamstrings as the three taught tendons running behind each knee.  But the term can also refer to three important muscles (each sounding a little like dinosaurs), bicep femoris, semitendinosus and semimembranosus which deliver, for example, running, kicking, walking functions to your lower leg.

  1. They extend the thigh at the hip – draw the leg in a backwards motion.
  2. They flex the leg at the knee – bend the leg in a heel to glute motion
  3. They act as an antagonist to the quadriceps – like ‘brakes’ to decelerate the forward movement of lower limb motion

As well as these functions, hamstrings can rotate to fine tune lower limb mechanics and help stabilise at the pelvis.

Your hamstring muscles are attached to your skeleton by tendons: tough fibrous structures that anchor muscles to bone.  The hamstrings are attached to the top of your lower leg bones (tibia and fibula) then run all the way up the back of your legs to connect to the Ischial tuberosity, or sometimes referred to as the ‘sitting bone’ in your pelvis (underneath the gluteal muscles). Damage any of these critical structures, and you are literally ‘hamstrung’.


hamstringCredit image to:  http://orthoinfo.aaos.org/topic.cfm?topic=a00408

So what is a Tendinopathy?

Hamstring tendinopathy is most commonly seen in mid- to long-distance runners and active individuals over 50 years of age, and, if not treated properly, it can be a persistent and recurring problem.

In order for sufferers to get the most appropriate treatment intervention, we first need to determine the stage of your injury. These are classified as:

  • the reactive stage
  • the degenerative stage.

NOTE: Correct diagnosis of which stage will have a huge influence on the proposed course of management (discussed later).

The reactive stage

If a tendon becomes over-stretched, stressed or strained, it may sustain micro-tears, causing acute localised inflammation. This is an early stage tendinopathy often resulting from a rapid increase in tendon loading, i.e. an increase in activity, a change in training or a return to sport after a period of rest.

Like any acute injury, it should not be ignored; if managed appropriately, the tendon should make a complete recovery and heal in a relatively short period of time.

If you think you can ignore it and it will go away, read on…

The degenerative stage

Serious issues occur when the tendon is subjected to continuous repetitive forces. Those who adopt a ‘no pain no gain’ approach beware, the injury rate overrides the healing rate, causing tendon deterioration, collagen degeneration (a protein providing strength and elasticity to tissue) and an overall change to the tendon structure.

If degeneration becomes advanced, the tendon may become thickened, weak and susceptible to rupture!

What are the symptoms of a hamstring tendinopathy?

‘A vague aching, soreness along or high up in your hamstrings, deep to the glutes’

Unless associated with a one-off trauma, symptoms tend to creep on out of nowhere, gradually becoming progressively worse.

  • Pain in the gluteal region, or in simpler terms – your bum. This can become particularly painful when sitting on hard surfaces
  • Stiffness and pain along the hamstring muscle – particularly in the mornings or after a prolonged period of rest
  • Pain and a perceived weakness on contraction – i.e. bending the leg against a resistance
  • Irritation of sciatic nerve – pain radiating down the back of the thigh and leg
  • Pain and a sensation of vulnerability when running, kicking or jumping – this is usually experienced during the acceleration phase

Why me? Why now?!!

While hamstring tendinopathy is typically due to recent increase in repetitive and unsustainable loading, there are many other factors which may have predisposed or maintained your condition.

It’s my job as an osteopath to determine the root cause, but in a nut shell…

  • Age – sorry guys, getting old can suck; less adaptable, less functional, slower healing response, time to start taking care!

But… don’t simply think being under 50 makes you invulnerable…

  • Change in activity/intensity – Upped your miles? Style? Resistance? Taken up a new sport? Sometimes our body isn’t quite as adjustable as we’d like.
  • Muscular imbalances – Are your hamstrings taking up the role of other muscles and being overworked? Poor glute activation is a big one!
  • Weak and tight hamstrings – This could be for an array of reasons, but once again, this is my job to work out why.
  • Inadequate warm up and poor stretching – Tut tut… we all know we should do it!

How can I fix it?

Firstly I’m going to get this out of my system; we all know the best way to improve a hamstring injury it is to ‘stretch it out’… Right? …Well actually I disagree, especially when you are in the ‘reactive, early stages’. Some practitioners may have differing opinions, but if the mechanism of injury is due to micro-tears and excessive compressive forces, why subject the muscle to further stress? Sounds a bit like applying heat to a burn.

  1. Rather than stretching your hamstring, try reducing tension using massage, trigger points, or a foam roller.
  2. Eccentric loading will improve tensile strength of the tendon, but it’s all a little too late. Stop eccentrically loading the hamstrings (i.e. straight leg deadlifts). The compressive and tensile forces are huge and so you’re likely to aggravate the symptoms if still in the reactive stage.

Now for the interesting part; this is an injury which in almost all cases is related to sports activity and if you’ve received osteopathic treatment from me in practice, you’ll know by now that I try to keep people active and encourage them to continue their sport… even if it has caused the injury in the first place. How? Simply by MODIFICATION. We modify and adapt what you do, to place the least stress on the affected structure. So here are a few examples

  • Reduce your running stride – smaller, shorter steps; the hamstrings are stretched far less and so are placed under much smaller degree of tension, reducing the applied forces significantly
  • Adapt your kicking style – by leaning backwards slightly, less compression is placed on the hamstring tendon at the ischial tuberosity (sitting bone)
  • Switch the treadmill for off-road running – treadmills impound on the same structures over and over again and enforce that repetitive loading. Get some variation
  • Split your activities – rather than running 10 miles x 1 weekly, run 5 miles x 2 weekly
  • Maintain strength – replace isokinetic training with isometric resistance training.

What we can do for you

  • Effectively diagnose and determine stage of tendinopathy
  • Identify mechanical imbalances and predisposing factors such as poor glute activation, weak core stability, and various factors contributing to tight and weakened hamstrings
  • Provide exercise aimed at restoring any determined imbalances
  • Soft tissue massage to relieve muscle tension, pain and reduce local inflammation
  • Joint mobilisation to improve range of movement available and restore potential pelvic misalignment
  • Medical acupuncture directly to tendinous junction which is scientifically proven to reduce muscular tension and pain
  • Sports and kinesiology taping to provide support, pain relief and function
  • Advise and educate appropriate footwear, rest periods, ice, orthotics, exercise programmes aimed at strength and mobility, i.e. foam rolling.

What you can do for you

Reactive stage

  • In the very early stages, give your injury a little break – don’t let this become a long term issue, respect your injury – better to be out a little than a lot.
  • When you return to running or your sport of choice, apply the modifications discussed with your osteopath – I’ve listed a few examples above.
  • Ice – Use cold compression to reduce inflammation
  • Anti-inflammatory medications (always consult with GP or pharmacist)
  • Foam rollers & trigger point hamstrings – by reducing and relaxing any tension in the muscle belly, you indirectly reduce any unnecessary loading of the tendon.
  • Isometric contraction lay on your front, and attempt to bring the heel to glute, work against a solid force i.e. partner applying resistance: hold resistance – 10 seconds x 5
  • Reduce negative loads that seem to aggravate symptoms in day-to-day activity, i.e. sitting on hard surface without a pillow.

Degenerative stage

  • Rest – this is all to do with management, tendons will adapt to an increase in load, but they need adequate time to do so; allow 2 or 3 days between training session and increase intensity slowly
  • Educate yourself – get to know and understand factors which aggravate your tendon, make a mental note of this and make some changes i.e. a cushion on that hard work chair
  • Trigger points and massage – use a tennis ball to work directly at the tendon insertion (where it attaches to the bone) to break down ‘adhesions or scar tissue’
  • Gradually increase mileage/intensity of training and keep a steady pace with shortened stride – Avoid: deep squats, lunges, deadlifts, hill sprints, treadmills
  • Eccentric training – it’s generally accepted that eccentric training is a useful part of managing degenerative tendinopathy. Improve tensile strength to reduce potential of reoccurrence.

Stay fit and enjoy!