High Hamstring Tendinopathy Rehab Protocol

Triathlon Forum
1

I have posted here serveral times over the last year regarding a hip/hamstring/glute problem that has now been definitively diagnosed as tendinopathy at the hamstring/adductors insertion (diagnosis by injecting the area with a deadening agent and then seeing if I had pain - I had zero). I have had a few ups and many downs with this injury over the last 18 months and have experienced nothing remotely so difficult to get over in my athletic life. If there is one lession I have learned and would tell others on ST it is that it just takes forever to improve and if you do just a little too much too one day you can set yourself back months. Trying to train even lightly with this is just too much of a balancing act. At this stage I am trying the last option I am aware of, platelet rich plasma injections, having had my first shot a couple weeks back and going for my next one next week. My doctor, who seems like a good one and says he has successfully treated this condition with PRP, says that my injury is one he sees more often in cyclists than runners because it is very medial and includes the abductors as well as the inner hamstring. He also said the most optimistic recovery time is 4-6 months. No noticeable improvement yet but I have not really tried to do much either. And this bring me to my question: rehabilitation protocol. My doctor has told me no ice, no nsaids, no strength training of the hamstring for now (too weak) minimal stretching (needs to heal), weekly massage and accupucture is ok as is light activity that gets the blood flowing but does not aggravate it. Problem is I can do a light ride of an hour some days and be fine but other days I will be fine but then it will be achy later in the day.

I would be incredibly appreciative to hear from anyone who has come back from this condition and what you did to do so, particularly in the early stage of rehab + what did you use as a guide for your activity level so as not to reinjure it.
thanks,
Jack

2

I dealt with hamstring tendinopathy and trabecular edema for a little over two years. PT made my hamstrings strong but did nothing for the condition itself. Shockwave therapy (similar to that used to break up kidney stones) did nothing. Finally got PRP (platelet rich plasma) therapy and that really made a huge difference. It is now about 90% back to normal.

Good luck,
Jim

3

Sounds similar to what I have been struggling with for over a year now. One doctor has called it ischeal tuberosity. Most of the pain is out at the upper part of the hamstring and then in where the hamstring tendons attach to the ischeal bone. I finally had a injection two weeks ago (so at least I could get through the IM without too much pain in that area) and it definitely feels better. I am going to PT, but have really never seen much result from that. I don’t know if I should just stop training both the bike and run for an extended period or to continue with the madness of trying to train but always hurting some. I think just sitting keeps it somewhat aggravated. Messed up my A races the last two years, really don’t want to make it three. Please let me know how the PRP goes.

4

Jsmith, I talked to you before about this injury. And yes, it was fixed :stuck_out_tongue:

Here’s the outline of what happened:

-Get the injury and see a lot of bad doctors and get no where. I rested the injury for 6 months with no improvement.

-Finally after 6 months of rest I go to a doctor for a PRP injection. He ends up NOT giving me the injection. He said he could fix it with a rehab protocol in only 3 months, and if I still had pain I could come back for the PRP. I decided to do the program (honestly I didnt believe it would work at first).

-1 month after following the program I am 85% better and able to bike without a problem.

-3 months after following the program I am 99%

-No PRP injection needed :slight_smile:

Rehab protocol (Everyone is different, but this is what they had me do)

No cycling, elliptical, pooling until I had pain free range of motion.
No running for 3 months

Weeks 1-2:
-wobble board
-Thera band speed skaters (This is a glute medius exercise)
-Double then single legged bridges
-Lateral band walks with thera band (for hip abductors)
-Front planks
-Side planks
-Hamstring curl with ball (Picture in the article I linked at the bottom)
-Good mornings with NO weight. Should feel only a light stretch

Later Weeks (Now for the good stuff, the eccentric exercises)
All of those exercises made more difficult by stronger bands / more reps

-They then added what I like to call the face plant exercise (http://www.youtube.com/watch?v=GBfHwWX6lak) However I did NOT do the concentric portion. When I got to the floor they had me push myself up, not use the hamstrings on the way up.

-The good mornings were changed to single stiff legged deadlift.

Interestingly enough, these exercises were done every other day. I did not do the eccentrics twice a day nor did I do it everyday. I know that most programs say to do the eccentrics 2x a day 7 days a week, but that was not the case for me.

Also:

-The doctor prescribed dry needling once a week
-I had ART done each week and used the foam roller
-Had a chiropracter align more hips

This article was phenominal, it was how I diagnosed myself before even visiting the doctor http://www.agilept.com/downloads/high-hamstring-tendinopathy-in-runners.pdf

The female runner in the articles case study had the hamstring problem for nearly 2 years and after 3 months of the rehab program she returned to running and by 6 months elite racing.

She did the exact same treatment I outlined:

1)Proper hip alignment (most people with this injury have an anterior pelvic tilt causing extra strain on the hamstring)
2) Cross frictional massage / ART
3) Core strengthening, especially working on the glute medius
4) Eccentric Hamstring Exercises

If you have anymore questions feel free to ask.

5

Wow, this is just uperhelpful. I really, really appreciate it.

My questions
-My main question is about pain free range of motion. Can you explain a little more what you mean? For instance, right now I have no pain walking or sitting but can feel it tugging at the insertion point if I do any sort of light standing hamstring stretch or a good morning rep (though the actual range of motion/stretch is the same as the uninjured leg). When I try to ride in fact, it is usually fine for the first 30-1:00 then I notice tightness/twinges/spasms at various points along each of the hamstring muscles that increase with time but the hamstring insertion itself usually does not really hurt when actually riding if I don’t go too long (though if I stop riding and try to stretch after about an hour or more I can feel it has tightened up at the insertion, also it will be sore there later in the day). I guess what I am trying to figure is how much total rest from activity should I give it given its current condition/strength before engaging in the week 1-2 protocol that you have listed? Do I have to wait to begin the rehabbing until I can do a light hamstring stretch or good morning and not feel it?

-What are the speed skaters? I have done the lateral walks with a band but not speed skaters.
-What do you do on the wobble board and for how long?
-The doctor you saw who put this plan together - I couldn’t be so lucky that he is somewhere near Washington DC?

THANKS AGAIN,
Jack

6

My hamstring tendinopathy is on the lateral side of my knee at the top of the tibia. I did the 8 months of rehab between mis-diagnosis of ITB and have been suggested PRP. My insurance doesn’t cover it so I am a grand out of pocket for each injection. I have delayed having it done in hopes of a miracle. Do you think your training protocol will work given that this is a different area but still related to the hamstring?

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@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.php?figures=89?figure=75 pain free then you can start cycling and elliptical.

However, when my doctor allowed me start cycling it was only for 30 to 45 min easy to moderate (Only on the trainer). He said to wait until I was 95+% to start actually training on the bike.

When I tried to bike (before rehabbing / getting a dx) what would happen is that around 25 to 30 min I would get this really tight knot in the middle of my glute that would cause pain everytime I pressed down on the peddel stroke.

You should be able to start the first week of rehabbing. But as the article I sent you states, if you cant perform that ROM test pain-free then your only activity should be upper body erg / swimming with a pull buoy.

No running for 3 months at least. Once you can do the linked test pain free I’d bike 30-45 min easy

Wobble Board- started out working on double and single leg balance for a few mins. Progressed to balancing with eyes closed. (Worked on it just 2-3 min)

Speed skaters- I will send you a picture of it later, I just spent a good 15 min googling for it (Im sure there is another name I cant think of) , but couldnt find it.

Unfortunately the doctor is in Atlanta.

@Inthehunt

What rehab did you do for those 8 months? Did you do any eccentrics exercises? The “faceplant” exercise I linked in the video hits the distal hamstrings very well.

For the PRP, I cant really say what to do. My doctor told me that if I got the PRP injection done before I lengthened the tendon (through 12 weeks of eccentrics) that it would just be a waste. So he said to do 12 weeks and if I still had some pain he’d do the PRP.

8

Once again, extremely helpful. I have been trying to get this sort of specific, practical information about of various PTs, doctors, etc for months - thank you!

I did the test and it is just barely noticeable at the very end of the ROM. I will start with the week 1-2 protocol, maybe swim with the pull buoy and then see in a week or so if it has progressed so that I can try the trainer for 30 minutes. Got my second PRP shot next week so hopefully together this will send me on the long road back to painfree riding and running. God, I hope so.

Send info on the speed skaters whenever you can and thanks again!

Inthehunt - one thing I learned in the course of this epic journey is that even the right rehab exercises won’t help if you don’t do them in the correct sequence. Living in europe last year I had a PT who gave me eccentric straight leg deadlifts to do daily but the problem is that the hamstring was that I was also still trying to ride and the hamstring was just not yet strong enough to that sort of thing so it could recover from the exercise and get stronger. You really need to start from square one with this thing, a fact I am just now understanding.

Jack

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who is/was your doctor?

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Dr. Garten at Atlanta Sports Medicine

11

whats your adductor strength? I bet adductors are weak and hamstrings are being recruited to stabalize.

12

Breif update for others dealing with this condition. I have now had 2 PRP treatments so far and I have finally noticed a distinct improvement in terms of pain free range of motion, though I still have a ways to go before I am riding or running like I used to. The clue about the adductors is a good one: I have been stretching them from several different angles several times a day for a couple weeks and really noticed my hips loosening - myabe the hamstring was stabilizing and that was what was overstressing it. Not sure if its the PRP or the looser adductors or not training much (doing the every other day exercises mentioned previously in this thread, some core work and riding on a spin bike easy for 30-1:00, no running) but things seem to be moving slowly in the right direction. Still have some tightness near my SI joint but my PT thinks that should fade as my adductors loosen up. Be interested in any suggestions for exercises that strengthen/lengthen the adductors from anyone who has dealt with or treated this condition.

13

For the PRP, I cant really say what to do. My doctor told me that if I got the PRP injection done before I lengthened the tendon (through 12 weeks of eccentrics) that it would just be a waste. So he said to do 12 weeks and if I still had some pain he’d do the PRP.

Agree with this, did protocols of PRP with no results. You need to fix the issue causing the problem before this will help the tendon.

Good info here, been trying to find others with this issue for a while. Been out 2 years now and just starting to see some improvement…

14

Sorry I have been MIA.

@Jsmith

When you ride on the bike what do you feel in that 30 min / hour? Do you get any knots or tightness, any pain?

Also I forgot to add that you need to have any anterior pelvic tilt corrected. After I had the injury for so long I started getting some pain near the SI joint on the injuried side. I had a chiro do the hip adjustments and let the PT do their eccentrics stuff.

I’m glad you are feeling relief from the 2nd PRP, but dont go out running anytime soon just yet. The rehab is what knocks this injury out and also prevents it.

@FishH2O

I remember you saying you still have the problem, but have you done an eccentrics program?

Also where are you located, I might know some doctors that can help?

If you have any other questions feel free to ask, its a pain in the ass of an injury.

15

TTC,
Right now I can ride a spin bike fairly easy for 1:00 with no issues and can do the hamstring range of motion test with no pain - this is a solid step in the right direction from where I was but obviously still a long ways to go. As recommended, I have not run or been on the bike outside at all yet. I have been getting consistent massage/PT to loosen and the muscles onmy glutes/hip for over 3 months now but only recently have I also had treatment on the adductors and focused on stretching them several times a day. As someone else said, I am thinking the adductors on my left leg have been tight/not firing causing overcompensation (and ultimate damage to my hamstring group) as well tension (and resulting tightness) on all the connected or opposing muscles (quadratus lumborum, glute medius, piriformis, tensor fasciae, etc). Next PRP is 10/7.

The hard part for me going forward is going to be gradually improving without doing do too much too soon. What would you suggest to add in for eccentrics for hamstrings/adductors (what/how much/how often) to the original first two weeks program you gave us earlier? Also, how did you go about gradually increasing your riding to the point you could get outside again - what did you use as benchmarks for further progression?

thanks again for all the advice,
Jack

16

Thanks for posting this, I have been through every type of physician possible and nobody has a clue. Already have a chiro and rolfing to address tightness and alignment. Will hammer at the exercises…

17

Thank you for your informative posts. they have helped me diagnose this condition. I have had it for 9 months. I did some of the exercise and have been running training for my A race with reduced milage and no speed. Started after long runs but looking back I had R butt pain while driving for 2yrs, about as long as I have been running. My condition isn’t as bad as I can still run and bike but the runs are often with pain unless I take a break for a few days. I ran my first marathon and now would like to heal this injury. I plan to stop running for 3 months and do the exercises, massage. I have a questions about the number of repetions that you started with and what was your progression in intensity and number. I plan to bike as it rarely bothers me but at moderate pace. Thank you for

18

Sadly yes, I’m in Chicago and have not been able to kick this. Partly due to my continuing activity (to some level), but I ask every practitioner if I should stop and have not received any legitimate feedback.

Mine goes back about 2 years +, I believe the trigger was plyo classes after IM in 2007. Post IM I was trying to ramp up my run speed as it is the limiter in most of my races. (:53, 5:20, 3:49). Oly is even more egregious. It began with some soreness after running deep in the gleut. Tightening on long car rides, etc. After a few months, it just got worse and worse. I can still run, but it strikes if I try to up the tempo, and is always sore. In my last Oly, it cramped up so badly after the bike, I just limped the run. It essentially became a permanent knot in my ass. I’ve gone through three chiros, two PTs, ARP Wave therapy, PRP, etc. Most have no clue, and the PT’s always seem to be designed to treat couch potatoes. I am also hyper flexible so I still have above average hammie flexibility even with the injury.

I currently have a Chiro who is somewhat on the program. There is a very good Rolfer in the office who is working on loosening the hips, hammie, gleut med and periformous to try and get things back into shape. I also have a separate masseuse who can magically get the knot to loosen, but it comes back to some degree. The key I am missing is exercises/training - they are working on this, but don’t have a facility at the moment.

I have been doing some exercises like the ones above, and feel like it is making some headway. I have not run in 8 months, but I have been cycling (road, mtn, cyclocross). I tried a HIM to see how the bike went after getting re-fit, and it just flamed out after 40 miles. The fit showed that I was using my hammies far more than the quads, likely contributing to the issue.

My plan is to stop riding in December after cross season for three months to try and kick this, but to really stick to the exercises above. Any advice, or other treatments/docs would be welcomed.

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@Jsmith

After the initial 2 weeks I would start with:

Hamstring Ball curl- 2x 12 to 15 reps (do the eccentric phase slowly)

Do double legged hamstring ball curls, later on your progress to single leg.

Faceplant exercise- http://i.ytimg.com/vi/qA82YSc5OH4/2.jpg where you slowly resist falling forward. Then push your self back up to starting position with your arms.

Start off with 2x15 to 20 reps

I know many studies say that eccentrics need to be done 2x a day 7 days a week, but in my experiance (and I am not a doctor) this doesnt work for this injury.

I recomend doing these eccentrics 1 to 2 days in a row. So either do them every other day, or like this:

M: Eccentrics
T: Eccentrics
W:Nothing
Th: Eccentrics
F:Eccentrics
Sa: Nothing

Etc

20

Thank you for posting this!!! I am so glad I caught sight of this post last night…I have been dealing with this for 10 years!!! I now have renewed hope that I can run pain free again!! I have seen the posts in the past (dealing with this), but no treatment protocol was given/suggested. I have done (almost) all of the exercises suggested, but the approach was pretty random, did not follow a set guideline, just knew I needed to strengthen glute medius…didn’t completely stop running (just reduced time, frequency, pace). Seems the eccentric hamstring exercises are pretty crucial to the long term fix of this. So, my questions… TTC, how long have you been pain free? If it has been a while (greater than 6 months of resumed “normal” training), do you continue the exercises? Since you have been “pain free”, have you had some flare ups? and if so, were you able to “contain” them? I have been pain free at times for up to a year, but it has always come back…with a vengeance! I have also tried the PRP injection with no relief (one injection, again…a random try at “curing” this with no protocol/guidelines). I haven’t really run since late May because of this recent “flare up” (got my first DNF ever because I could not run after the bike…and I’ve been racing tri’s 20 years).