The 6 stages of Proximal Hamstrings Tendinopathy Recovery

Proximal Hamstrings Tendinopathies (PHT) is one of the most annoying conditions we see at the clinic.

Although very rare in the normal population (only 0.5% of the population), PHT accounts for approximately 3.1% of all tendinopathies in athletes. And I would say that this number is a lot higher in runners….

“A quick note…

Tendinopathy is what used to be called a tendinitis or tendinosis or tendonosis…. And since nobody seems to agree on the right terminology, they added a new posh one - Tendinopathy - which group of all of the other terms….

No doubt they will change that again in a few years….

And because we are always ahead of the game at the surgery we tend to call tendinopathies, tendon pain , which is way cooler….”

You will have guessed PHT affect the tendons of the Hamstrings muscles which all attach on the ischial tuberosity, commonly called the sitting bone.

The Hamstrings muscle work together to extend the hip and bend the knee. They also help stabilise the pelvis when in movement.

What Causes PHT?

Tough one to answer. It is one thing to diagnose PHT, it is another to understand why it happened.

PHT is generally caused by a combinations of factors.

Intrinsic factors are causes that are part of the individual, such as:

• Anatomy (Leg length discrepancy, for example,)

• Decreased flexibility,

• Joint laxity,

• Age (Reduction in muscle fibre size and number are associated with advancing in age, this leads to losses in mass and strength - oh what fun!),

• Overweight,

• Tightness/Weakness of the hamstrings and quadriceps,

• Poor lumbopelvic/core stability

Extrinsic factors are influenced by the outside, such as :

• poor training,

• environmental conditions (weather, playing surfaces, etc.)

• poor equipment,

• Insufficient warm up,

• fatigue,

• the demands of the sport itself.

The difficulty is to work out what ones might affect in the injury.

The onset of PHT is mostly gradual, and generally not associated with acute trauma (although one of my dear friend did hers doing a cartwheel!). The pain is localised on the tendon just under the buttock crease. Pain can travel down the back of the thigh at times.

Pain will be produced by activities requiring deeper hip flexion i.e. squats, lunging, long periods of sitting and will be increased by long distance running.

The 6 stages of PHT Rehab

The six stages includes three “physiotherapy” stages and three sport specific.

PHT return to sport pathway for football

Stage 1: Promote healing of the injured tissues.

This is the typical physio treatment. That phase will lasts between 72H and 4 weeks depending the extend of the injury and will include rest, ice/cold, massage and , electrotherapy (ultrasound, laser, TENS, etc.).

It has been also shown that patients receiving a course of Shockwave Therapy will have better outcomes that patients you don’t….

Exercises will be started as soon as possible with gentle Isometric loading exercises to build load tolerance and offload the irritated tendon :

• isometric leg curl

• isometric wall squats

• Bridge holds - hip in neutral

• Isometric straight leg pulldowns

• Trunk extensions

• Isometric long leg bridging on two, progressing to one leg holds

Stage 2 - Start loading the tendon.

This stage will focus on isotonic hamstring load with minimal hip flexion to to restore hamstring muscle bulk and capacity in a functional range of movement.

• Single leg bridge

• prone hip extension

• prone leg curl

• Nordic hamstring exercise

• Bridging progressions

• Supine leg curl

Stage 3 - Increase the load.

During that stage, we will focus on dynamic exercises with increased hip flexion angles to continue with promote hamstring muscle strengthening in greater hip flexion.

• slow hip thrusts

• forward step-ups

• walking lunges

• deadlifts

• Romanian deadlifts

Stage 4 - Plyometrics.

During that stage , we will start hops, jumps and many plyometrics tasks. These exercises are called energy storage loading exercises as tendons act as a 'spring' in storing and then releasing energy.

• Sprinter leg curl

• A-skips

• Fast sled push or pull

• Alternate leg split squats

• Bounding

• Stair or hill bounding

• Kettlebell swings

• Lateral, rotational cutting movements

Stage 5: Sport-specific loading.

Full sports specific exercises and eccentric loading are then integrated. The exercises will depend on the sport and its demand.

Stage 6: Full Return to Sport.

By the end of stage 6, the athlete should be symptom-free during all activities and will have completed 3 progressive sports specific sessions with no pain before running to normal sports.

 If you have any questions about your hamstrings injury, please don’t hesitate to contact us on info@benjiphysio.co.uk.

We're committed to working with you every step of the way to ensure a successful recovery and a return to the activities you love.