A Pain in the Rear: High Hamstring Tendinitis

Case Study
Mary, a 45-year-old runner and triathlete, has been unable to train for the New York City Marathon because of a pain in the buttock and sit bone region. She works at a computer and frequently sits for six to eight hours a day. She will sometimes feel lower back pain that includes a sharp tingling down the back of her leg. She is able to run at a very slow place but cannot complete her long runs or perform any speed work due to pain at her sit bone.
As exhibited by Mary's case, the injury is characterized by a deep pain at the site of the ischial tuberosity or "sit bone." The condition begins with soreness after running but progresses to pain with activity and often soreness with the direct pressure of sitting. In most cases the pain comes on without any acute event but rather increases over time with continued running. As the runner can often have a history of lower back pain, the symptoms frequently include a radiating pain that crosses the knee, suggestive of nerve inflammation from the lower back. After a longer period of high hamstring injury, changes in running gait are sometimes apparent as the runner begins to "ride" over the leg and not use the hamstring complex to propel the body forward.

The three hamstring muscles (biceps femoris, semimembranosus, semitendinosus) have a common origin on the ischial tuberosity of the pelvis. This common tendon is subjected to a high degree of tension as the hamstring muscle group propels the body forward during running. This repetitive tension can lead to an overuse injury of the high hamstring tendon. Treatment of the injury should initially address identification and treatment of any lower back involvement with a visit to an orthopedic surgeon or spine specialist. Once lower back pathology has been ruled out or treated, treatment of the high hamstring can begin. The important areas to address are strength of the hamstring, hip and leg, flexibility, and soft-tissue mobilization of the tendon and hamstring. Since running is an aggravating factor and is likely preventing the healing process from beginning, it is best to find other means of cardiovascular exercise.
Mary makes several ergonomic changes to address her lower back symptoms, including avoiding the slumped position, not sitting for longer than 15-20 minutes without a short standing break and temporarily avoiding hamstring stretching to allow the sciatic nerve to heal. Mary also begins an exercise program that emphasizes general leg strengthening and avoids direct hamstring exercise. She stops running and starts riding a stationary bike and swimming to cross train.
The purpose of the initial phase of the treatment process is focused on cross-training and general hip and leg strengthening (quad, calf, gluteal muscles, hip abductor). Special care should be taken early in the reconditioning process to avoid too much stress on the healing tendon. Direct hamstring work, as with a hamstring curl machine, can be aggravating to the tendon and should be avoided at this stage. Direct hamstring stretching should also be avoided or done cautiously to prevent overstretching an inflamed sciatic nerve or hamstring tendon.
After a reconditioning and healing period of six weeks, Mary no longer feels the same level of soreness at her high hamstring tendon. She is able to begin full weight-bearing training on the Stairmaster and elliptical trainer and adds direct hamstring strengthening exercise into her rehabilitation program. Mary also starts to stretch her hamstring and uses a foam cylinder to massage the hamstring muscle and tendon.
After this protective phase is completed, more specific hamstring work can begin, as detailed in the included exercise program. As a general criterion, once hamstring strength is nearly equal, a light running program can be initiated.
Prevention of hamstring problems mirror the later phases of the rehabilitation program. Those without any hamstring problems will benefit from maintaining or improving hamstring and leg strength and can incorporate direct hamstring work into the initial exercise program. All phases of exercises, as detailed in the exercise program, can be used. Another important factor in preventing high hamstring problems is avoiding excessive stress to the lower back. As in the case of Mary, being mindful of sitting ergonomics can help with those who sit for long periods of the day. The important factors are avoiding the slumped position when sitting and taking frequent sitting breaks.
The process of returning to running after an extended period of high hamstring injury can be a long one but can be done successfully with a patient and thorough reconditioning program. As with any injury, early intervention is the key to minimizing time away from running. Many studies have shown the importance of resistance training for endurance athletes, especially as they age.

See more: