High Hamstring Tendinopathy Rehab Protocol

Triathlon Forum
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What factors did you and the doctor weigh in to come to PRP conclusion? What is PRP recovery / rehab protocol? I’ve considered this as well, but @ $600/ea, not a cheap option. I’m currently seeing Dr. who specializes in ART. Hoping to see some relief soon.

I’ve been fighting this on the left AND an annoying right plantar fascia/peroneal tendonitis issue for a while. The PF has been an issue since summer (July-ish). The high hamstring is a bit more difficult to determine the start, as I’ve had sciatica in that same leg, with similar symptoms for years on and off. When this issue re-emerged, we thought it was sciatica at first, and so I trained through it, with a cortisone shot (which I would not have gotten if we thought it was a tendon issue).

I’ve also already tried ART, PT with dry needling, activity modification, and rest. When I saw the PRP doctor, I brought him all my MRIs (I’ve had 3 - right foot, left hamstring, lumbar area), and my full case history. He said I was a “very strong candidate for PRP” in both the foot and the hammy. Separately, in the past I’ve always responded well to the more provacatory treatments - Graston, cross-frictional massage, dry needling, etc. Which points towards this working for me.

In deciding to go ahead, I consulted two PT friends, two other people who have had PRP (both of whom said they’d do it again), and my own PT. And my coach. Everyone said to go for it if I could afford it. And I can. And I REALLY want to be able to start training for Boston in January.

Rehab afterwards is a bit TBD. I’m getting it on Friday, and planning to be on the couch through the weekend. Then swimming with pull buoy only for the first part of next week. Part of the reason it’s TBD is that we’re not quite sure where I’m getting the PRP. Since the hammy issue still has some sciatic aspects to it, we’re doing the following:

Thursday - get blood drawn

Friday morning early - I run two miles, then get some painkiller injections in hamstring tendon area. Then run two more miles. Depending on how that second run feels, he’‘’ make a recommendation about whether we do just hamstring tendon, or also back.

Friday afternoon - PRP

As for rehab, I’ve been doing eccentric exercises and running with some improvement, but very slow.

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Thanks for your detailed breakdown. Please keep us posted on how your PRP procedure goes and how your rehab shakes out. If PRP can get my partially torn tendons back in the game after only 8 weeks as it sounds it may for you, it would be worth the money. I’ve been struggling with this since May. Activity modification, rest, loads of PT, and a dexamethasone shot all providing no relief.

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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.

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In my case, swimming aggravated it, too
.

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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 think if it’s been going on for several months, and you’re not quite sure what you’re dealing with, an MRI is unquestionably appropriate.

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I think if it’s been going on for several months, and you’re not quite sure what you’re dealing with, an MRI is unquestionably appropriate.

I really would like to get an MRI but my insurance sucks because the deductible is so high that the MRI is pretty much my expense. Also, dont you think no matter what the MRI reveals, the doc would say to rest? Maybe I just need to shut down for a week or 2 and then start with the process mentioned in this thread.

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Well first of all, I am NOT a doctor. But second of all, my entire family is in the medical field, and one thing I’ve learned from them is that the clinical exam is more important than scans/MRI. But the benefit of the MRI is that it can help distinguish between several possible diagnoses, each of which might have a different treatment strategy.

for example, we thought my issue was exclusively sciatica, and treated it that way, which wasn’t optimal for a tendon issue. The MRI helped clarify the issue and change the plan. But if you and your doctor are sure that you have high hamstring tendonopathy, then maybe no need for MRI. But it sounded like you weren’t sure, and also hadn’t been seeing results over time. In that case, I’d ask for an MRI.

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So, an update. Did the PRP on Friday - decidedly unpleasant (painful). Then was totally sedentary for 48 hours (Saturday-Sunday). I was very sore from the PRP for about 6 hours after, and moderately sore the next morning. As of 5 days later, the attachment point is still a bit tender.

On Monday-Tuesday I swam some with a pull buoy and did some very gentle rehab exercises (nothing that hit the hammy specifically, just glute bridges). On Wednesday I went in for PT, and was told to shift to normal swimming, and then start phasing in the elliptical.

I went for an easy 3000 yards this morning - was going for 4000, but the hammy started getting sore, so I stopped. Interesting thing is that the hammy did NOT hurt when doing freestyle before the PRP, except for the occasional twinge. This morning, I definitely got some soreness radiating down the hamstring. Don’t know what to take from that - I do know that I’m still very early in the PRP response, so it hasn’t worked whatever magic it has yet. But uncertain as to whether I should back off on the swimming for a few more days. I have an email in to my PT to ask.

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Did you get an update as to any specific PRP rehab protocol from your PT? your hamstring tendon still sore? I’m considering PRP as well, but it would be bilateral for me … :frowning:

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Did you get an update as to any specific PRP rehab protocol from your PT? your hamstring tendon still sore? I’m considering PRP as well, but it would be bilateral for me … :frowning:

It was the belly of the hammy that was bugging me along with the attachment, but that’s how my injury has been (and why it was first confused with sciatica). There’s definitely some impingement of the sciatic nerve.

PT wasn’t too concerned. Said that I should try swimming, alternating 500 yards buoy with 500 yards normal. If I wanted to be really conservative, I could stick to the buoy for a day or so. It was a bit sore this morning, so I stuck to the buoy.

Separately, I’m doing lots of bridges with my feet at different distances from my rear. From there, the progression will be to “walking out the bridge” to something closer to supine plank, and then back again.

Everything I’ve heard about PRP is that for the first 2 weeks it can make things worse, and the effects don’t kick in until 3-4 weeks post procedure. So I’m not too concerned.

It does seem to me that the people who have had the most success with PRP took it VERY easy the first 2 weeks. On the other hand, my PT feels very strongly that right now it’s better for me to be doing exercise that gently engages the area and uses the range of motion, rather than total rest.

The site of the injection at my ischial tuberosity is still tender, a week post injection (conversely, my foot isn’t tender at all). Fortunately, I telecommute, and so I’ve been able to position myself in a way that spares the sit bone.

I’m actually hoping that the tenderness is a good sign - seems that those with more soreness post-procedure also benefited most, based on the very small sample size of blogs and friends I’ve consulted. Like I said, my foot isn’t tender, but that didn’t need treatment anywhere near as much as the hammy.

Question for all other sufferers - do you JUST have pain right at the sitbone/attachment? Or do you also have soreness down the upper third of your hammy?

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I am teetering on the edge of going with PRP injections. One ortho is all for it, another says it won’t help. How has your recovery been coming along, now that you’ve had PRP?

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I am teeterieng on the edge of going with PRP injections. One ortho is all for it, another says it won’t help. How has your recovery been coming along, now that you’ve had PRP?

I’m not quite at the 2 week period post PRP, so still too early to make a call. I’ve been told by others that the first 2 weeks I’d feel the same to worse, and then I’d see a general trend of improvement there after. PRP is not a quick fix, just a quicker and more complete resolution.

That being said, I’ve noted somethings that seem positive. I still have a bit of pulling sensation in the hammy, but my range of motion seems improved (my pt noted this as well, even before I did). When I bend down to pick something up off the floor, I don’t reflexively protect it anymore. And I’ve noted improvement on many of my PT exercises, though I’m not yet to the point where I can do a supine plank pain free.

There seems to be a positive trend. And I’m not sure it could be explained by just the rest - I did that before (took a week off) with no real improvement.

But again, still too early to be certain.

As for whether to go ahead, my decision basically came down to…the worst case scenario was that I spent money and endured some discomfort for nothing. There wasn’t the same downside risk to PRP that there would be to surgery or a cortisone shot (not that surgery was ever discussed in my case). And I’m really hoping to be able to train for and run Boston, and so was willing to risk wasting money if it possibly improved my chances of healing in time.

I’ll definitely keep you in the loop as to how things progress. I do note that I am STILL a bit tender right where the shots were (it’s now the 13th; I had the shots on the 1st).

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Before I started ART 5 weeks ago, pain was localized to just insertion point on ischial tuberosity. Now my tendon at the insertion point is the most painful it’s ever been and I do have some pain in the upper third of the hamstring muscle. My ROM is less too (because of heightened pain). No more ART for now … I’m really hoping I didn’t make things worse by trying it.

Darkwave - you’re 20 days into PRP rehab … how are things going thus far?

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Darkwave - you’re 20 days into PRP rehab … how are things going thus far?

Short version: Things are progressing, though slowly, and in a “take a step forward, take a half step back” way.

Longer version (in case details are helpful).

Since I last posted, I’ve progressed back to full swimming freestyle for 3000-4000 yards (did 50/50 pull buoy, then 25/75, then canned the pull buoy altogether). I also added in some walking.

I got a deep tissue massage done last Wednesday (10 days post PRP), and my massage guy RAVED about how good the hammy felt. So that was nice.

I’ve also noted that I’m no longer protecting the hammy in my daily activities. For example, I bend down to pick something up without shifting or twisting to spare it. And I just checked my range of motion, and I’d say the left hammy has about 95% the range of motion of the right. That’s a big improvement.

For rehab exercises, I shifted from doing just normal bridges to “walking out the bridge” - basically going into bridge, then walking out to nearly supine plank, and back in. On Sunday, since I was tolerating that exercise fine, I transitioned to eccentric hamstring ball curls. I lie on my back, with my feet on exercise ball, then go up into a bridge pose. Then roll the ball out, so that I’m in supine plank with feet on ball (the eccentric part), lower my rear to the ground, and pull the ball back in.

Nice thing about today was that I did that with no pain on the eccentric part (some mild pain on the bridging part).

On Sunday I did 8 minutes on the arc-trainer. That went fine, so I did 20 minutes on Monday. It felt fine during, but was mildly stiff and achy afterwards, and I worried I had overdone it. I emailed my PT (he wants emails every few days) and he told me that some mild achiness was to be expected, and that I should try the arc-trainer a few times more, noting how I felt. If things don’t improve after three sessions, then we’ll back off. But it’s normal for there to be some achiness after reintroducing anything, so I should give it a few more tries.

I’ll fess up that I also jogged 3 steps, twice, in the parking lot to test it. (I couldn’t resist). That did NOT go well. Definitely not ready to run yet.

So plan for the next few days is more bridges, more eccentric hamstring balls, more arc-trainer. I feel like I’m definitely seeing improvement. But I just wish I was off of the emotional roller coaster.

In terms of flexibility, I’m much better than I was pre-PRP. In terms of how I feel while swimming, about the same. Based on the three steps I took running, that is still WORSE than pre-PRP (I was running with moderate discomfort before). But I also haven’t run in nearly three weeks.

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Before I started ART 5 weeks ago, pain was localized to just insertion point on ischial tuberosity. Now my tendon at the insertion point is the most painful it’s ever been and I do have some pain in the upper third of the hamstring muscle. My ROM is less too (because of heightened pain). No more ART for now … I’m really hoping I didn’t make things worse by trying it.

BTW, in my experience for ART, the practitioner matters a lot. I’ve had some very effective ART, and some that has made it worse. There are some people that are just too rough when administering ART. In my experience, if it hurts a LOT while getting it done, it doesn’t help much. ART that is just moderately uncomfortable helps a lot.

I don’t suppose you’re in the DC area? I do have two people in the DC area that I trust for ART.

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thanks for your very detailed update, much appreciated. I will use your rehab updates as a baseline as to what I might expect if (likely when) I try the PRP injections.

You’re right about ART. the first 2-3 weeks there was mild discomfort, nothing bad, and I felt like I might be heading down the right road. The last two weeks he hit those tender tendon spots hard, maybe too hard, and I’m in worse shape because of it.

In Grand Rapids, MI … thanks for the offer though.

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Just another update. I’ve seen some more improvement the last few days. I’m still a far way from “healed” but definitely improving.

On Thursday, the hammy started feeling a lot better, so I jogged a few test steps in the gym. And…no pain. So, I hopped on the treadmill and did 3x90 seconds VERY SLOW jog, split by 60 seconds walking. No pain, just a sense of weakness. I was slightly stiff after.

On Friday morning, did a bit more of the same. This time it was 4x90 seconds jog, 60 seconds walk. (still - very slow. I maxed out at 4mph for the jog - by contrast, I ran my last marathon in 3:08, so this is REALLY slow). Followed up with another 20 minutes on the arc-trainer. Very slight stiffness after that resolved within 30 minutes.

This is small stuff, but still feels like great progress.

Other development is that I was getting a bit more pain from the eccentric hamstring ball exercises, so my PT asked me to “step back” slightly. Basically, I’m shifting to doing bridges with my feet propped up on a bench. I’m starting with both feet, and then will progress to doing it on one foot, with the other foot assisting. When that is pain free, I’ll shift back to the hamstring ball curls.

I was scheduled for my next PRP appt on Dec 2nd, but my PT suggested that I push it back at least a week to get a better feel for how things are progressing. He and I are both thinking that further PRP may be unnecessary. PT wants me to slowly progress to regular runs before seeing him again.

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Thanks again for the update, I really appreciate it. I’m sure others that are suffering from the same affliction can learn from your experiences. Glad to hear too that you are making some positive gains. If you had to summarize your 0-4 week rehab protocol for PRP, what does it look like? In other words, what exercises is your PT having you do at his facility, and what exercises are you doing at home/gym? I imagine you want to keep the proximal hamstring area engaged without overdoing it.

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Well. I’ve just seen the end of 3 weeks (had the PRP on 11/1 - it’s now 11/23)

Here’s how my rehab looked so far:

days 1-2. nothing. Lay on couch all day, try to use hip as little as possible.

days 3-5. start back with Egoscue posture exercises, a few glute exercises and stuff like side planks. Also swim with pull buoy.

Days 6-12. Start transitioning from swimming only with pull buoy to swimming normal freestyle. Also start doing glute bridges walking legs out to near prone and back, as well as glute bridges with my shoulders on ball.

Day 13-16 - start adding in some walking.

Day 17 - add in use of arc-trainer, starting with 8 minutes and progressing over next few days up to 20 minutes. Also add eccentric hamstring ball curls.

Day 20 - add in some gentle jogging on treadmill at very slow pace, starting with 30 seconds walk, 30 seconds slow jog

Day 21 - decided that eccentric hamstring balls a bit too much, so swap to doing bridges with heels up on bench.

My current rehab protocol is:

  1. an extended set of marching bridges with my shoulders on a ball, lifting one leg and then the other, while keeping my pelvis level. - I do about 4-5 sets of 10, but I’m focusing more on correct execution than actual # of reps

  2. bridges with my heels on a low bench - doing 3 sets of 10 or 2 sets of 15 twice per day.

  3. alternating jogging and walking on a treadmill. Aiming for no pain here. A pain level of 1-2 is OK on the bridges exercises, as long as it doesn’t linger. I do not currently feel pain on exercise 1. I do feel some with exercise 2.

BTW - the above is just how it has played out for me, not a prescribed schedule. My PT did NOT give exact #s of reps, or exact days on which I should shift from one exercise to another. He and I have worked together for several years now on different injuries, and he knows me well enough to “trust” my judgment on how many reps and when to progress. When I see him, he does some manual therapies (ART) and also assesses the injury (checking flexibility, strength). Then we discuss how my exercises have been going, and he checks form and maybe shows me a new one or two. Then I update him every few days by email before the next appt (seeing him every 10-14 days).

If it helps, my training log is here: http://www.runningahead.com/logs/e7c610f1924249cb99ae86f3d600517f/calendar

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Just another update. I’m at 4.5 weeks post PRP, and jogged 4 miles at easy pace, no pain. Legs are tired from lack of fitness, but I’m still thrilled.

Was it the PRP? I’ll never know for sure, but I’m thrilled with where I am.