Understanding Hamstring Tendinopathy
The hamstring is the long, bulky muscle on the back of your thigh. It consists of 4 separate muscles which originate on the back of the hip, travels down the posterior thigh, and attached to the back of the knee. The hamstrings are a very important stabilizer of the knee, hip, and pelvis. If the hamstrings become strained or overloaded pain can occur in the back of the thigh, back of the knee, or in the back of the hip where the muscle originates from the ischial tuberosity (the bone on the back of this hip you sit on).
In our experience almost every case of hamstring tendinopathy is related to 1) a biomechanical problem as the hip that is creating excessive strain on the hamstring, or 2) a sciatic nerve problem. These issues must be addressed to fully resolve the hamstring problem (see discussion below).
Signs and Symptoms of Hamstring Tendinopathy
- Gradual onset of pain and/or tightness on the back or side of the knee, or in the back of the thigh
- when the upper tendon is involved there will often be a pain in the upper-posterior thigh or hip, and there may be pain with sitting
- Stiffness or tightness of the hamstring group (back of the thigh)
- In the early stages, pain symptoms usually improve with warm-up or exercise
- In later stages, pain may worsen and be present during the activity.
What Causes Hamstring Tendinopathy?
Hamstring Tendinitis / Hamstring Tendinopathy is an example of a repetitive strain injury. Unlike a traumatic injury which is caused abruptly following a trauma or accident, repetitive strain injuries (referred to as an RSI for short) are associated with very small amounts of tissue stress and damage that, if not addressed, can accumulate slowly over time and lead to pain.
Here’s how this works….
As the hamstring is stressed and over-used it can lead to small scale damage in the muscle and/or hamstring tendon. This damage is referred to as ‘micro-trauma. Although only small this damage still needs to be repaired. The body does this by forming new tissue in and around the injured tissue. This new tissue, often referred to as scar tissue or soft tissue adhesions, is very sticky and acts to ‘glue’ the damaged tissues back together. For an analogy, think of a big rubber band with a pinprick in it. This pin-prick does not affect the rubber band much, but we still want to repair it so we put a little dab of glue over the area.
If the overload at the hamstring continues (this is almost always associated with biomechanical problems at the hip or a restriction in the sciatic nerve, see below) there will be ongoing micro-trauma and subsequent repair of this micro-trauma. Overtime, this scar tissue will build up and will start to interfere with the normal strength and flexibility of the hamstring. Going back to our analogy, think of this as more and more pinpricks in that rubber band, followed by a big build-up of glue around the area. This will, in turn, make the rubber band stiffer and weaker. As scar tissue builds-up in the hamstring, it cannot stretch or contract as well. At this point pain and in the back of the knee, or back of the thigh will develop. If the upper portion of the hamstring tendon is involved there will be a pain at the top of the back of the hip where the hamstring attaches into the bone.
Why the hip and pelvis are important with hamstring tendinopathy
It is important to realize that many cases of hamstring tendinopathy are actually caused by a problem at the hip or pelvis. If the muscles around these segments are not working properly it will force the hamstring to contract harder than normal during such as walking, running, climbing stairs, or with exercises at the gym. The hamstring is essentially forced to compensate for these problematic muscles. (“Do you want to know if your knee pain is linked to a problem at your hip or pelvis? Try squat test, 1 leg squat test, or lunge test). If these issues are not resolved the hamstring pain will not fully resolve, and will likely come back in the future.
Is your hamstring tendonopathy caused by a sciatic nerve problem?
In addition to muscle problems at the hip and pelvis, a restriction in the sciatic nerve is also a common cause of hamstring overload. The sciatic nerve is the major nerve that supplies the muscles, joints, and skin of the leg. As the nerve travels down the leg is passes between, underneath, or in some cases through many key muscles of the leg (including the piriformis, hamstring, and soleus muscles). Under normal circumstances, this nerve must be able to move and slide along these muscles. However, if any of these muscles develop scar tissue adhesions (which occurs with repetitive overload, see above) the sciatic nerve can become stuck or glued to these muscles. This is turn prevents the nerve from sliding along the muscles, and instead, the nerve is over-stretched with leg movements. This can damage the nerve, so when the nerve becomes restricted the body must find a way to protect it. It is common for the body to increase the tension in the hamstring as a protective mechanism (this limits motion at the hip and knee and prevents the nerve from over-stretching). Although this solves one problem it creates another as over time the over-activity of the hamstring can lead to a hamstring problem. (To see is a restricted sciatic nerve restriction may be causing your hamstring pain try a Sciatic Nerve Tension Test).
Treatment – Resolving Hamstring Tendinopathy
The proper treatment of hamstring tendinopathy must not only address pain and tissue damage at the hamstring itself, but MUST correct and biomechanical problems at the hip or pelvis, or any restriction in the sciatic nerve if either of these factors are present.
For treatment to be effective we have found that there are certain steps that must be followed, and these steps must be performed in the right order if we are to expect the right results. Here is our approach when treating hamstring tendinopathy in our clinic….
Step 1 – Resolve scar tissue adhesions and facilitate healing
Perhaps the most critical step is to treat the scar tissue adhesions. These adhesions are a sign that the hamstring (or other surrounding muscles or sciatic nerve) is not healthy, and unhealthy tissue will not respond as well to traditional stretches and exercises – think of trying to stretch out that rubber band caked with glue. Resolving scar tissue adhesions is a critical step in resolving hamstring tendinopathy, but it is often a missed or underappreciated step as many practitioners do not have the clinical skills to address this problem.
Scar tissue adhesions do not resolve with stretching or traditional massage or soft tissue methods, but instead must be treated with specialized techniques. One of the most effective methods is to use a technique known as Active Release Techniques (ART). For those who are unfamiliar with this treatment method, ART is a new and highly successful hands-on treatment method that was specifically designed to identify and address scar tissue adhesions that are interfering with the normal movement of the body.
During an ART treatment, the practitioner will first shorten the muscle, tendon, ligament, or joint capsule and then apply a very specific tension with their hands as they stretch and lengthen the tissues. As the tissue lengthens the practitioner is able to assess the texture and tension of the tissue to determine if the tissue is healthy or contains scar tissue that needs further treatment. When scar tissue adhesions are felt the amount and direction of tension can be modified to treat the problematic area. There are ART protocols to treat specific muscles and tendons, as well as restriction in the sciatic nerve.
Step 2 – Correct strength and flexibility
Simply treating the scar tissue adhesions will make the damaged tissue healthier, and will often result in a significant reduction in pain. In fact, it is not uncommon to see a significant improvement in just a few visits. However, although addressing the scar tissue makes the muscles healthier, they may still be somewhat tight or weak. When this is the case-specific stretches or exercises can be incorporated into a home exercise/rehabilitation routine to help support in-office care. Initially, the focus is on correcting local muscle deficiencies (i.e., at the knee, hip, or foot).
Step 3 – Re-Train Functional Movement Patterns
The final stage with treatment is to ensure proper alignment and movement coordination of the foot, knee, hip, and trunk with functional movement patterns. This ensures movement of the hip, knee, and foot are coordinated and working together as a unit. This is what is required during real-life activities such as running, walking, cycling, and climbing stairs (the key functional movement patterns with respect to hamstring tendinopathy include the squat, 1 leg squat, and lunge).
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