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Re: High Hamstring Tendinopathy Rehab Protocol [bsherman] [ In reply to ]
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bsherman wrote:
darkwave wrote:
Mixed feedback.

Ortho: I'd just stick to swimming only until it stops hurting. However long that takes. I don't think PT is necessary, but you can go there if you want.

PT: This MRI isn't matching what we're seeing clinically. It's fine to do nothing but swimming for a week, but then I want you to try some easy jogs and see how it feels. He's also been doing dry needling, and gave me some eccentric exercises.

I also ran it by a teammate who is a PT - she wasn't that worried about my MRI, and commented that there were probably a lot of people out there with some sort of tear in their hamstring tendon that were asymptomatic.

So, I'm confused.


I have been watching this thread for a while because the symptoms I have sound spot on with everyone else. My right side sits bone has been sore for about a year but it has been fairly manageable as I have been able to train but not like I really want to. I have seen 2 PT's over this time and still sore enough that it keeps me from training like I want to and driving a car is uncomfortable. First PT said I was weak in core, so I have spent 12 months strengthening core and glutes. Second PT did ART and e-stim. After my last race (70.3) 2 1/2 weeks ago I have done nothing but swimming about 4-5 days/week and continued my core and glute exercises 2 times a week, no running, no riding. After 17 days still no relief, maybe even worse than before. I would have thought that after this short break from running and riding I would have had some relief. Is it possible that swimming aggravates this? To get to the bottom of this, what type of doc should I seek out? Is an MRI is in order? My primary doc ordered a scoped steroid injection in June and it got rid of the soreness for about 2 months.

I've been asking myself the same question: Is swimming responsible for the hamstring tendinopathy b/c it began when I ramped up my swimming volume from 500 yrd/week to 5,000 yrds/week (yes, it's too fast, but I thought that not much bad could happen from swimming).

What is your perspective now?

Proud Representative of Slowtwitch Anti-Atheists Society.
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Re: High Hamstring Tendinopathy Rehab Protocol [noneoftheabove] [ In reply to ]
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bumping this b/c its relevant to me. Just got recommended to get another MRI and ultrasound done on hamstring. Just had labral reconstruction in my left hip and this started just as I was picking up biking again. I've been slow and steady. This though is something that showed up on my original MRI. I don't have the money to just try PRP so I wanted to see if anyone that did found that it works.
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Re: High Hamstring Tendinopathy Rehab Protocol [darkwave] [ In reply to ]
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I just had PRP last week for this injury and have been reading and re-reading this thread closely. I first had problems on Thanksgiving and only got a firm diagnosis 6 weeks later. Since then, PT has been very specific for hamstring with eccentrics and core strengthening, and I've been able to do elliptical and deep water running. I'm hoping the PRP kicks in in 6-8 weeks and that I get the green light to start the return to running and biking protocol. I'm signed up for the New York marathon in November. What do people think? Is that realistic?
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Re: High Hamstring Tendinopathy Rehab Protocol [theroadback2016] [ In reply to ]
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Any updates on the PRP?

Also, are the symptoms for this and piformis similar? I think I have tendinopathy but I just can't seem to shake it!
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Re: High Hamstring Tendinopathy Rehab Protocol [theroadback2016] [ In reply to ]
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I'm also located in NYC and heading in to get a PRP injection today. Any specific advice for what to do / not do in the days after? How quickly were you able to get back to any type of low effort crosstraining (walking, stationary bike, eliptical)?
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Re: High Hamstring Tendinopathy Rehab Protocol [jarrod] [ In reply to ]
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Well, it has been a while, but I think the PRP really did the job, though my recovery was slower than some of the other people posting to this thread. I'm now 7 months out from the PRP and am running 3 days/week with a slow but steady weekly mileage increase. I took it really easy, per doctor's orders, for 8 weeks after the injection--no workouts, just light walking to and from the car, around the office, etc. Resumed PT work at 8 weeks. Started to re-introduce running in 1 minute bouts a full 4 months after PRP and have been steadily adding time/mileage, all the while continuing the PT regimen.

Patience is the key. Good luck.
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Re: High Hamstring Tendinopathy Rehab Protocol [jsmith] [ In reply to ]
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I read the thread on this topic and can agree that HHT is a big pain and very frustrating even for a recreational runner like myself....in addition the constant pain while sitting makes it difficult to enjoy everyday life. After much trial and error, (i.e. spinal injections, SI injections, etc).... I was diagnosed in Nov 2015 and an MRI confirmed a partial tear in my right hamstring and hamstring tendinopathy in both hamstrings. I have been to several PT providers (regular PT , ART PT), chiro who performed Graston, 2 PRP injections (right hamstring only.....done at suggestion of doctor who wanted to see if I had any relief before trying the left hamstring)....

The ART PT wants me to continue with eccentric exercises and slight hamstring stretches, my chiro does not recommend any hamstring stretches, etc.....my niece who is a newly minted PT is suggesting dry needling....as you can see very confusing as I have been getting conflicting guidance.....bottom line is this has been going on for 3 years now....

Does anyone have a recommendation for a doctor in the New York/New Jersey area who has specific experience in providing/managing a protocol to treat HHT.....would greatly appreciate any guidance...
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Re: High Hamstring Tendinopathy Rehab Protocol [joer] [ In reply to ]
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I don't have an. Doc suggetion, but I had some degree of relief from dry needling, much better than any combination of Graston, ART, etc.

I would also be very suspect of any diagnosis from a chiro in this area unless they also have PT or similar license. Just my $.02.

Chicago Cubs - 2016 WORLD SERIES Champions!!!!

"If ever the time should come, when vain and aspiring men shall possess the highest seats in government, our country will stand in need of its experienced patriots to prevent its ruin." - Samuel Adams
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Re: High Hamstring Tendinopathy Rehab Protocol [jsmith] [ In reply to ]
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jsmith,

After reading your posts I'm convinced I have the same injury. I broke my tibula and completely tore my interior ligament when I was 18 from skateboarding. I moved on to cycling and in my later 20s started to develop symptoms in my high hamstring. Stopped cycling all my 30s then came back with a vengeance in my 40s putting on 10000 mi my first season back. Then the symptoms really came on hard with the pain coming only when I sit. I have been misdiagnosed at least twice and now nobody dares to give me any kind of tx or diagnosis but I'm convinced I have high hamstring tendinopathy. Ive had it for over 6 months. I'm using a neck pillow to sit on to keep the pressure off that interior hamstring tendon and using holistic medicine: turmeric and solomons seal. Its working but I found very valuable information reading your story. From your ankle injury to no stretching and rest to out of whack hips. I almost think we should collaborate and write a book on this injury management lifestyle we are in and the quackery that got us here.
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Re: High Hamstring Tendinopathy Rehab Protocol [TTC] [ In reply to ]
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TTC wrote:
@Jsmith

If you look at page 8 of the article I sent you it says that if you can do this test: http://www.physsportsmed.com/...figures=89?figure=75 pain free then you can start cycling and elliptical.


TTC: I know this was a very old post....but I'm intrigued to know what test you are referring to above. I have the exact same history really, and am keen to know when I can return to light cycling (it's incredibly frustrating to be immobile!). the link does not appaer to work now....can you possibly clarify?

many thanks!
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Re: High Hamstring Tendinopathy Rehab Protocol [srg] [ In reply to ]
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Bump, because I'm curious too.
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Re: High Hamstring Tendinopathy Rehab Protocol [jstonebarger] [ In reply to ]
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This is the best thread in the www regarding high hamstring tendinopathy. I have a question. Do you get problems when running and cycling?
I developed this deep pain through cycling over 2-3 years. Last year I started trail running because I could not stand the pain anymore. I get absolutely zero problems when running. Finished a half and a marathon and I can run full speed up and down the steep mountains.
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Re: High Hamstring Tendinopathy Rehab Protocol [Cattiy] [ In reply to ]
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I feel obliged to write a little something about this since I see soooo many replies in this thread where people have been completely mislead by their medical professional. I'm a final year PT student with a special interest in pain science, tendinopathies, movement in general and sports and triathlon in particular.

First let me explain Jill Cook's continuum model about tendinopathy:

As you can see, a tendon that has been put through more load than it can take will become reactive. This is what many of us athletes have felt when ramping up swimming or running volume: our shoulder/achilles start hurting. It's a load-induced hurt and the pain is usually 0/10 in rest. Taking a few days off, maybe some ibuprofen and like magic, its gone. That is "appropriate modified load" for the reactive tendinopathy.
However if one continues to apply excessive load, or if any other individual factors becomes worse, the tendinopathy will not resolve by itself and will enter a dysrepair/degenerative phase. This is often called "chronic" tendinopathy because it's much tougher to get rid of, but as you can see looking at the model "appropriate modified load" can get you out of the degenerative phase as well.

So what loads a tendon?
Tendon is loaded by movements, and there is 3 types of load we can apply to the tendon.
The first, most basic load is tensile loading; this is simply done by flexing the muscle that inserts into the tendon. This is generally well tolerated even by a degenerative tendon. The amount of tensile loading is proportional to the muscles contraction (add weight and it's more loading). An example for achilles tendinopathy is to just raise your heel 1 inch off the ground, standing on your toes. A easy way to quantify this type of load is to start with isometrics and count time under tension. Isometrics might also immediately reduce tendon pain through a mechanism way out of scope for this text, but its a cool thing to try. A good isometric for proximal hamstring tendinopathy is the supine bridge.
The second type of loading is compressive loading. This is when a tendon wraps around a bony structure and is put under tensile loading, compressing it towards that bone. A good example is the peroneal tendons, wrapping around the lateral malleolus:

This type of loading is often aggravating for tendons. The reason is also beyond this text. Here is a pic which describes where the common tendons are compressed.

The third type of loading is energy storage; what tendons are best at. This is also often aggravating and especially if it is combined with compression (like the peroneal tendons or distal achilles tendon when running). This type of loading comes from a passive lenghtening of the tendon from an external force when the muscle is 'locked' isometrically. Think of the calf complex when running; the calf will contract isometrically but the foot will reach maximum dorsiflexion at mid stance; this loads up the tendon with mechanical energy that will be released at toe-off.


So this gives a very basic understanding about what tendinopathies are; an inability to tolerate the current load. By modification to this load, we can create adaptation and get the tendon functional and pain-free again. How long this takes depends on how long you've had the tendinopathy, individual factors (training response, morphology, psychological factors, etc) and how much demand you will put on your tendon.

So how does one start rehabing a tendinopathy?
Step one is to find your current load tolerance and build from there. Start with tensile loading out of compressive positions. For the foot's tendons this means maximum plantarflexion, for the proximal hamstring tendinopathy it means maximum hip extension (since the tendons wrap around the ischial tuberosities when the hip is in flexion, such as in the time trial position or when you sit on a chair. Sitting also increases compressions since well, you sit on it). Start with an isometric program only for a few days and see if this calms the tendon down or aggrevates it. If you tolerate it, start doing some actual movement. If you dont, reduce load. Keep track of what you do and add in more exercises the more you can tolerate. When you can do pretty much, start adding in some compression. When you tolerate this, add in energy storage. It's all simple in writing but takes time, tears, commitment, experimentation. It's like ironman finish times; easy to do it fast on paper.

An example progression of exercises for proximal hamstring tendinopathy could be this:
W1: 3x30s supine bridge, adding some time daily
W2: 6x45s supine bridge with extended legs, feet resting on something
W3: 5x60s suping bridge, feet up + 3x10 ball curls
W4: 1x60 supine bridge, 3x10 ball curls, 1x10 dynamic supine bridges (glute bridge)
W5: 4x10 ball curls, 2x10 glute bridge, 1x10 one-leg glute bridge
W6: 3x10 glute bridge, 2x10 one-leg glute bridge, 10 one-leg straight leg deadlift
W7: 2x10 glute bridge, 3x10 one leg glute bridge, 2x10 one leg straight leg deadlift
W8: 3x10 one leg glute bridge, 3x10 one leg straight leg deadlift, 3x5 deadlifts

Somewhere in there one can also start running, it's energy storage but with pretty little compression.

Hope this gives some insight and also makes you question all the passive modalities that it seems like every PT/GP/Chiro prefers here in the US (injections, dry needles, different ways to hurt you with tools like graston/art whatnot). A tendon needs load, a tendinopathic tendon needs smart, well progressed load. Good luck!

Endurance coach
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Re: High Hamstring Tendinopathy Rehab Protocol [mortysct] [ In reply to ]
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Thanks for posting this info.

Quick question - the supine bridge.....does it actually do something to the hamstring directly, or is it more about strengthening the glute, which in turn will give the ham a break?
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Re: High Hamstring Tendinopathy Rehab Protocol [SBRcoffee] [ In reply to ]
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They are both hip extensors. Possible a stronger glute will take load of the hamstring, but tendinopathy rehab is primarily about increase the load capacity of the tendinopathic tendon. It's a progression into something more hamstring-dominant, like the ball curl. Start easy and increase load over time. If you can get to a gym, the lying leg curl is of course a great machine. Possible to work eccentrics as well on that one (but it's not necessary to work eccentric only for tendinopathy rehab, but its a progression if eccentric-concentric is too much load right now

Endurance coach
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Re: High Hamstring Tendinopathy Rehab Protocol [mortysct] [ In reply to ]
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Thx a lot! By your post I am able to to all of your excersises including running but cannot tolerate compressed loading for example while cycling.
If sit more forward on the saddle nose on my road bike I get no problems but this position gets uncomfortable. If I sit more upright on my MTB I also get less problems. How do I advance from here?
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Re: High Hamstring Tendinopathy Rehab Protocol [Cattiy] [ In reply to ]
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If you can tolerate w8 exercises but not cycling yet, do the week 8 exercises real heavy (5 reps of deadlifts at 6-8RM for example, and add weights in the glute bridge) about 2x week. For extra control and an additional effect, count 3 on both eccentric and concentric phases. You can even try to add in cleans to get some energy storage + compression loads.

Meanwhile you do this, do your cycling upright. There is still compressive elements in upright cycling but not nearly as much as in TT position. Gradually increase how much time in aero you can do, add a few minutes per week.

You'll be fine by summer. Maybe even faster, since resistance training improves running economy.

Endurance coach
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Re: High Hamstring Tendinopathy Rehab Protocol [mortysct] [ In reply to ]
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mortysct wrote:
If you can tolerate w8 exercises but not cycling yet, do the week 8 exercises real heavy (5 reps of deadlifts at 6-8RM for example, and add weights in the glute bridge) about 2x week. For extra control and an additional effect, count 3 on both eccentric and concentric phases. You can even try to add in cleans to get some energy storage + compression loads.

Meanwhile you do this, do your cycling upright. There is still compressive elements in upright cycling but not nearly as much as in TT position. Gradually increase how much time in aero you can do, add a few minutes per week.

You'll be fine by summer. Maybe even faster, since resistance training improves running economy.

I know it is key to avoid exercises that aggrevate the pain in the high hamstring. But let`s say when cycling I get 3-5 min of discomfort (not sitting good, to much power...) in my 40 min commute. Is it enough that I make no progession to heal the high hamstring?
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Re: High Hamstring Tendinopathy Rehab Protocol [Cattiy] [ In reply to ]
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I dont think so, no. Generally, when rehabilitating from tendinopathy, there will be pain.

Endurance coach
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Re: High Hamstring Tendinopathy Rehab Protocol [mortysct] [ In reply to ]
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Looking back it makes sense that avoiding compression is key. Last year in may, I bought a cross country MTB to try something different. My position on the MTB was of course more upright and I got much less problems (same position to the bottom bracket and same saddle). Unfortunately the higher Q-Factor of 155 mm and the SPD pedals did not get along with me knee, so I sold the MTB.

Before that I tried a full carbon saddle. Sat only on my sitbones and also got no problems. But in the end the saddle was to hard I got pressure damage on my left site, because of my uneven hips.

Maybe I try to ride without my Assos bibs and just some MTB shorts and seamless underpants, because maybe the thick chamois is to soft and leads to compression of the high hamstring. Was not an issue with the full carbon saddle, but with my "softer" Prologo Zero II CPC. The idea is that I ride softer than with a full carbon saddle and bibs, but on a harder surface than the Prologo Zero II CPC and the Assos bibs.
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Re: High Hamstring Tendinopathy Rehab Protocol [TTC] [ In reply to ]
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TCC, on the remote chance you may still be following this thread: The link you provided to an article with a test for pain-free readiness to commence the training program you followed is broken. Could you let me know what the name of the article was (or send a updated link)? Many thanks! Peter
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Re: High Hamstring Tendinopathy Rehab Protocol [Pladegaard] [ In reply to ]
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I second that!
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Re: High Hamstring Tendinopathy Rehab Protocol [Cattiy] [ In reply to ]
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Just a bump on this one with my on-going experience.

A couple of weeks or so out from IMNZ last year I pulled my calf (or so I though) stepping off a kerb. Did IMNZ anyway, although head wasn't in it and walked much of the run.

Anyway, to cut a long story slightly shorter, it got diagnosed as HHT after a series of X-rays (which showed nothing) and a couple of MRI's. I had a couple of rounds or PRP injections, which improved things, but only a bit. I still had issues which limited cycling and running.

Just over three weeks ago I had surgery "high hamstring origin repair" - surgeon is Dr Matt Brick (ex-triathlete and all-round nice guy) - although I had to travel to see him, as an ex tri-head he understood where I wanted to get to. He told me that the tendon was about 60% detached.

So, after only three weeks I still have pain, but it's getting better. I can walk without a crutch but can't sit down for very long. I have hopes of getting back into some gentle biking and running soon, but I won't be rushing it. In the meantime I have lots of nice pain meds to keep me happy!
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Re: High Hamstring Tendinopathy Rehab Protocol [quintana who] [ In reply to ]
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I wonder why a detached hamstring could not be seen on multiple MRIs? I am asking because I also had a MRI that showed nothing...
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Re: High Hamstring Tendinopathy Rehab Protocol [Cattiy] [ In reply to ]
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Cattiy wrote:
I wonder why a detached hamstring could not be seen on multiple MRIs? I am asking because I also had a MRI that showed nothing...

Or did they see it on the MRI, thus the decision for surgery? I'm going through the same type of injury, haven't had an MRI yet, takes forever in Canada... :(
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