Do you have a nagging pain or discomfort in your buttock when sitting? Does it feel like most chairs are too hard when you sit? You could have proximal hamstring tendinitis.
Hamstring tendinitis is a condition where one of the hamstring tendons is injured due to constant irritation from repetitive overload. This condition is most common in long distance runners, sprinters and sports with lots of changes in direction, like football and hockey, but can also happen if you spend hours and hours of every day sitting in front of a computer. You will have pain either at the top of the hamstring where it originates from your buttock (sitting bone) or at the bottom of the hamstring at the back of your knee.
Tendinitis is also known as a tendinopathy, tendonitis or tendinosis – these are all different names for the same injury of your hamstring.
What is the hamstring tendon?
A tendon is a band of tough connective tissue connecting a muscle to a bone and can be compared to ligaments. Both are made of collagen, but ligaments connect bones to each other and tendons connect muscle to bone. Tendons can withstand a great amount of tension and need a lot less blood supply and oxygen than muscles. This means that tendons don’t get tired as quickly as muscles, because they need to carry loads and maintain tension for long periods of time.
The hamstring muscles are a group of four muscles at the back of the thigh called semitendinosus, semimembranosus and biceps femoris. These muscles are attached to your “sitting bone” at the top by the proximal hamstring tendon and attached to the back and sides of your knee – one attaches on the outside and two on the inside of your knee – by the distal hamstring tendons.
What does the hamstring tendon do?
The main function of your hamstrings is to bend your knee and they also help with extension (backwards movement) of your hip. The hamstrings are used to propel your body forward, especially during running, jumping and kicking activities. When the hamstring muscle contracts, it pulls your hip backwards and downwards and it pulls your lower leg backwards to put your knee in a bent (flexed) position.
Your hamstring muscles can either shorten (concentric) or lengthen (eccentric) as the muscle contracts leading to tension in the tendons. This tension is what makes the tendons act as pulleys to move your hip or knee, resulting in your knee bending or slowly straightening.
Concentric contraction
A concentric contraction involves the hamstring muscles shortening during contraction, which puts load on the tendon as it has to produce a force to move your knee. An example of a concentric contraction, would be doing a hamstring curl in the gym.
Eccentric contraction
This is when the hamstring muscles lengthen under load. During a hamstring curl, the eccentric contraction would be when you lower the weight down with your leg (extending the knee).
How does Hamstring tendinitis happen?
Normal tendons
Healthy tendons are brilliant white in color and have a fibro-elastic structure that consists mostly out of collagen fibers. However, the blood supply and oxygen consumption of tendons and ligaments is 7.5 times lower than muscles. The fact that tendons have poor blood supply means that tendons need more recovery time after exercise or an injury.
Your hamstring tendons must be able to withstand the tension of the hamstrings pulling on it, like a car being towed: the cable must be strong enough to absorg the force when the car is suddenly pulled forward. If the towing car accelerates without taking up the slack, the cable won’t be able to withstand the sudden force.
What happens when you overload a tendon?
The structure of a tendon will change if repetitive strain is put on it. Either through compression or tension. The network of collagen fibers in a tendon gets disrupted by micro-trauma caused by too much strain leading to hypercellular activity, which is an excess production of collagen cells. As your body tries to heal the tendon, it produces more new collagen cells. However, this leads to tendon thickening and a loss of flexibility. Ultimately, this will cause weakening of the collagen structure.
The tendons must also be able to handle the compressive force every time you sit down (proximal tendon) or straighten your knee (distal tendons). The tendon is elastic, meaning it can stretch and recoil. However, straining the hamstring tendons during physical exercise and overburdening the tendon above it’s physiological limit can cause micro-trauma. Continuous micro-trauma and thickening of the tendon causes increased friction between the fibers. Changes in the tendon alters the ability and strength of the tendon to handle the load. This will lead to degeneration of the tendon i.e. hamstring tendinopathy.
Causes of hamstring tendinitis
The main cause of hamstring tendinitis is overload or overtraining. Concentric and eccentric contractions put a different kind of force/load on the tendon, where one shortens and the other lengthens. However, both of these activities, could lead to a hamstring tendinitis when done repetitively under high load, causing irritation and inflammation. Sudden changes in your activity – like a swimmer suddenly doing sprints – , intensity – doing 500 hamstring curls when you usually do 3 sets of 12 – , speed – increasing your pace too fast, surface – doing a trail run if you normally run on a treadmill – or the length of your training sessions without allowing enough recovery between sessions will overload your hamstring tendons leading to hamstring tendinopathy.
Factors that increase the risk of developing hamstring tendinitis are:
- Poor training
- Skipping your warm up
- Fatigue
- Leg length differences
- Muscle imbalances
- Decreased flexibility
- Age
- Increased BMI
- Hip stiffness
- Sciatica
- Impaired balance
What is the difference between ‘n hamstring tendinitis and a hamstring muscle tear?
Hamstring tendinitis is a degenerative condition that affects the tendons, so your pain will either be at the origin of your hamstring at your buttock or its insertion on the inside or outside or your knee. The first thing you will notice with a tendinitis is stiffness that gets better with activity.
A hamstring muscle tear affects the muscle belly, that is the “fleshy” part of the muscle at the back of your thigh. You will usually feel a sudden, sharp pain and there may be bruising and swelling in the area.
If you are unsure rather call us for an accurate diagnosis.
Symptoms of hamstring tendinitis
How bad is my hamstring tendinitis?
Tendinitis can be classified into three different stages. It starts with acute hamstring tendon pain and if the right steps are not taken to get the tendon back to a healthy state, it progresses. The structure of the tendon weakens over time and can start degenerating and disintegrating.
1. Reactive tendinitis (First stage)
The acute phase of hamstring tendinopathy (reactive tendinitis) is caused by a change in the amount of work that your hamstring tendon needs to do. Straining, overload and overburdening the hamstring tendons are the main factors causing this condition. Usually, in this phase there will be some inflammation and possibly swelling around the tendon or tendon sheath (synovium).
Let’s say you felt your hamstring ‘pulling’ during an uphill run, but it goes away after a while. Now you continue running every day for the rest of the week. At the start of each run you feel discomfort and stiffness in the lower part of your buttock (proximal hamstring tendinitis) or behind your knee (distal hamstring tendinitis), but it improves when you run. It can’t be that bad then, can it? When you push through this pain every time, you are repeatedly causing micro-trauma to your hamstring tendon. If you do not get the right treatment during this phase, the structure of the tendon starts to change and it gets weaker. At this stage the tendon has the potential to recover and revert back to its normal structure.
2. Tendon dysrepair (Second stage)
Reactive tendinitis (first stage) can progress to tendon dysrepair (second stage) if the tendon is not allowed to recover. During this phase there is continuous breakdown and disorganisation of the collagen network as your body tries to heal the tendon. This means that the collagen fibers are not neatly arranged in bundles, but tear away from each other, like a cable or rope where the individual strands break and separate. Applying more force will cause more damage.
In this phase, you will feel a dull pain in the lower part of your buttock or behind your knee at the start of your run, but it will linger a little bit longer, and bother you more and more. Now you start to feel the pain not just during your run, but also throughout the day with simple activities like sitting down or climbing stairs. As the tendon structure changes, it is not capable of doing the work it should and this causes you more pain. If you do not decrease the burden on your hamstring tendon injury and allow it to rest, further damage will occur and it can now lead to problems elsewhere, like your knee, hip and lower back.
3. Degenerative tendinitis (Final Stage)
Degenerative tendinitis is the final stage and at this stage the tendon damage is permanent because the degeneration of the tendon is irreversible. The structure of the hamstring tendon weakens further and adhesions form between the tendon and the sheath around it. Adhesions are patches of wound tissue attempting to heal the torn fibers. These adhesions, together with the fact that the tendon thickens, makes your hamstring tendon less flexible and the normal gliding movement of the tendon inside its sheath becomes impossible.
Now, the tendon cannot withstand even the stress and load of normal everyday activities like getting out of bed, climbing stairs and walking.
Diagnosing hamstring tendinitis
Our physiotherapists can accurately diagnose your hamstring tendinitis without expensive scans. We know and understand the anatomy of the lower leg, hip and knee and we know which other soft tissue structures could be involved with a hamstring tendinitis. We consider the the intricacy of the biomechanics of walking, running and jumping.
When it comes to hamstring tendon injuries we look at the big picture. We find out what is important to you and what you would like to achieve with your training. During your physiotherapy evaluation, we will be able to determine how bad your hamstring tendinitis is by stretching and stressing the tendon, as well as different joints and muscles in the area. We also test muscle strength and length, range of movement and can measure swelling in the area.
Sonar
If we suspect a hamstring tendinopathy, the best way to confirm the diagnosis is by measuring the width of the tendon. The injured tendon will appear thicker when compared to the other leg’s tendon. This is done by Sonar or Ultrasound (Diagnostic Sonar).
The Sonar will be very helpful and show which of the three tendons is affected (location) and how bad (degree) the hamstring tendinitis is. The radiologist may also indicate the stage of the tendinopathy which gives us a good idea of how long your recovery will take.
MRI or CT scan
MRI and CT scans are expensive test, but under normal circumstances the imaging by sonar is sufficient to pick up a hamstring tendon injury. If we suspect damage to the part of the bone the tendon is attached to an MRI or CT scan could be useful, but this will come to light during our assessment.
Why is my hamstring tendon injury not going away?
Tendons need time to heal
Treatment for hamstring tendinopathy can take quite a long time. It will feel like your pain takes a long time to improve, because tendons heal a lot slower than other structures and a hamstring tendinitis is the type of injury where you will have to change your routine. Tendons don’t like sudden changes in the amount of load they have to carry.
Tendons don’t like change
By increasing your walking or running distance, you increase the amount of work that your hamstring tendons must do. Increasing your speed, how often you train or the surface you train on are all things that increase the load on your hamstring tendons. In the early stages of a tendinopathy it will feel like your pain goes away when you start activities. You will notice stiffness the morning after exercise that gradually gets worse, if you carry on with this pattern.
The only way to address this issue is to modify the load on your hamstring tendons. That means that you must decrease your distance or speed, or you might have to do another form of exercise to let your hamstring tendons rest and recover.
Early diagnosis and treatment is key
You create a cycle of damage if you constantly overload or overuse the tendon before it heals. An overused or overloaded hamstring tendon causes pain, inflammation or disintegration of the tendon. It takes a long time to recover from this type of injury, which means early diagnosis is very important. Don’t wait too long before you see a physiotherapist and don’t push through the pain each time you move!
A big problem we see with hamstring tendinitis
Delayed treatment
A common problem we see is that patients wait too long before they seek help for their hamstring tendonitis. By the time they come to see us, they have had pain for 6 months to a year and they continued training. Now, the tendon structure has already started to change and weaken, leading to a longer recovery time.
Medication use
Often, patients try to take anti-inflammatory medication in the hopes of getting rid of their pain. However, this slows down the healing process and tendons already take longer to heal than other structures. The only long-term solution for your pain is to change the load that you put on your hamstring tendons. Taking medication will not fix your problem.
Not completing the physiotherapy treatment process
Another problem we see is patients stopping physiotherapy treatment too early. If you don’t complete the whole rehabilitation process, your pain will always come back. Patients generally “feel better” after the two weeks of pain management and thus continue on their own with their activities, only to come back after a few weeks with the same problem. The main aim here is not to merely get rid of the pain. It is important that we “clear” your hamstring tendon at the end of rehabilitation – we do this by retesting the muscle length, strength and the tendon’s ability to store and transfer load.
Cortisone injections
Sometimes we find that someone will go for cortisone injections to get rid of the nagging discomfort of a hamstring tendonitis. This treatment could help with some pain relief, but a side effect of cortisone is that it weakens tendons. If you don’t address the cause of the injury this pain relief is temporary, so when your pain comes back and you go for repeated injections, you risk a tendon rupture.
Stretching
The advice you will usually get from others is to stretch a stiff muscle, but you should rather ask yourself why the muscle feels stiff. If you have a hamstring tendinitis the muscle stiffness is actually your body trying to protect the injured tendon from further damage. Depending on the degree of damage to the tendon, you also risk a complete tear if you stretch through your pain. Rather contact us for the correct exercises for your hamstring injury.
Physiotherapy treatment
Different factors will contribute to each patient’s hamstring tendon pain. Therefore, we look at the bigger picture to find out what’s important to you and what you would like to achieve with your training. During your physiotherapy evaluation, we will be able to determine how bad your hamstring tendonitis is by stretching and stressing the tendon, as well as different joints and muscles in the area. As part of the assessment we also do nerve tests to find out if the sciatic nerve is contributing to your pain. To determine if there’s tightness in the area we will test the length of your hamstring muscles and we also test your muscle strength around your knee and hip.
Treatment will include:
- Advice on load modification is the most important part of tendon injury rehabilitation. If you don’t change the load on your tendon, the injury cannot heal and you will cause more damage.
- Electrotherapy, including laser and ultrasound, to help with pain relief and to promote healing.
- Myofascial release and dry needling to get rid of muscle spasm and tightness.
- Joint mobilisation to improve or restore the movement of the joints.
- Nerve mobilisations to restore the normal gliding movements of the nerves.
- Taping/strapping to support the area and deload the tendon.
- Exercises to strengthen your hamstrings and the stabilizing muscles around your hip and knee.
- Advice and education to help you to understand your condition and know what you can change to be in control of your symptoms.
Protection
Patients tend to ignore their pain and carry on with activities that make their hamstring tendon injury worse. Every time you ignore the pain the healing process in your tendon starts all over again, so it’s important to stop when you feel your hamstring tendon pain.
Education
A major part of physiotherapy is education. There are different possible diagnoses for buttock pain or pain around your knee.We’ll explain our findings & why. Our role is to guide you. We can answer all your questions and give you advice to help your hamstring heal faster.
Load
It’s important to manage load appropriately with any painful condition and this is especially true of tendon injuries. Too little loading can delay healing and cause other problems like stiffness, but too much load will just keep the vicious cycle of micro-tears and partial healing going. This causes more damage to the tendon until you tear the tendon or muscle.
We can guide you through the process of managing the load on your hamstring tendon to keep you moving without causing more damage.
Avoid anti-inflammatories
Anti-inflammatory medication can interfere with your body’s normal healing process and long-term use of medication increases your risk of side effects.
Exercise
The right exercises are important to get you moving, regain strength and speed up the recovery process. Complete rest will not change anything to your hamstring tendinopathy and you will find that your stiffness and pain increase if you stop moving.
2nd Phase: Pain relief and tissue healing
We monitor the progress of your hamstring tendinitis and track your recovery. Physiotherapy treatment for pain relief will include dry needling and electrotherapy like laser and ultrasound. These modalities can also help with tissue healing.
3rd Phase: Deload the injured tendon
In this phase of your treatment we find out what is causing your hamstring symptoms and focus on changing these factors. We will guide you in activities to avoid and how you can still stay active without making your injury worse. We will also strapping/taping to help take strain off the injured hamstring tendon.
Muscle tightness can also add extra stress to the already struggling tendon, so treatment will also include dry needling and myofascial release to relieve muscle tightness.
As your rehabilitation progresses we will gradually increase the load on your hamstring tendon again.
4th Phase: Open-chain exercises
During the first stages of rehabilitation you will start with open-chain exercises, in other words exercises where you don’t put weight on the injured leg. At first you will be doing isometric exercises where the muscle contracts, but your knee/hip doesn’t move. These exercises limit the load on the hamstring tendon injury and will be different variations of knee flexion (bending) and hip extension exercises.
5th Phase: Partial to full weight-bearing exercises
In this phase of rehabilitation you will start doing partial weight-bearing exercises, so your hamstring takes some of the load. In this way we can gradually increase the work your hamstring tendon is doing, without overloading it. During this time the treatment of your hamstring tendon injury will still include ultrasound, laser and soft tissue therapy like dry needling and massage.
As your pain and muscle strength improve we will progress to full weight-bearing exercises, using your own body weight as resistance.
6th Phase: Resistance training
At this stage your hamstring tendonitis should tolerate full weight-bearing exercises and we will start adding elastic resistance and weights. The added resistance increases the load on the tendon and at the end of this stage you will be doing heavy, slow resistance exercises. These exercises are important to change the tendon’s capacity to withstand loading which leads to long-term improvement in the your hamstring tendon pain.
7th Phase: Eccentric strengthening
A muscle contraction works in two directions: One where the muscle is contracted and it shortens like a hamstring curl (concentric), and controlling the descent going down from a hamstring curl (eccentric). Eccentric contraction loads the hamstring tendon fibers while lengthening under tension. Another example would be when you bend to the floor to put down a heavy box – your hamstrings help to eccentrically control the bending of your hip so you don’t just fall over.
These type of exercises are vital to condition the hamstring tendon fibers to absorb a force.
8th Phase: Stretch-shortening-cycle
At this stage you should be pain-free during weight-bearing and loaded exercises, so we will start exercises focused on the stretch-shortening-cycle of the tendon. This is when the tendon acts like a spring for explosive activities, going from a lengthened position (stretch) to a shortened position (contraction) in a short period of time. Exercises will be similar to those in the eccentric strengthening phase, but we will increase the speed and range of movement. A tendon should be able to withstand this kind of load without flare-ups or pain.
9th Phase: High speed, power and proprioception (if appropriate)
If you are returning to a specific sport, running drills will be some of the last exercises before you finish rehabilitation. These drills will include acceleration and deceleration, rapid direction changes and a combination of running and jumping.
The hamstrings tendons must be tested under high load and speed to ensure that the muscle and tendon will be able to keep up with the demand of your body. During this phase our physiotherapist will guide you to return to normal activities, as well challenges the muscle past its ‘normal’ boundaries to determine how it reacts to different forces and prepare you to return to participating in your sport.
How long will it take for my hamstring tendinitis to heal?
If you keep in mind the slow healing rate of tendons, then you can plan on physiotherapy treatment for hamstring tendonitis taking anything between 6 weeks to 3 months. Every patient is different and will have different goals. You could experience flare ups in between, but if the full rehabilitation program is followed, we aim to get you back as soon as possible.
The first few weeks, while dealing with the acute phase, we will need to see you twice a week to focus on pain management and healing. Thereafter we will see you once a week as we start with gradual tendon loading as part of your rehabilitation. As your pain improves and you get stronger, the spacing between appointments will change to one treatment every ten days then every two weeks. This ensures that we can progress the intensity of your exercises and eventually clear your hamstrings – making sure your hamstring tendons can handle load like it should.
Other medical treatments
General practitioner
Your GP can prescribe medication to help with pain relief in the acute phase. This can be useful when added to physiotherapy treatment, because we can start with rehabilitation once your pain is under control.
Cortisone injections
An injection directly into your already damaged tendon is not recommended, but cortisone injection into the soft tissue around the tendon can help with pain relief if physiotherapy treatment on its own isn’t effective. However, rehabilitation and strengthening is still crucial after an injection, because the cortisone only relieves the pain it doesn’t reverse the tendon damage or solve the problem.
Extracorporeal shockwave therapy (ESWT)
In this treatment a machine is used to administer shockwaves to the injured tendon. The theory is that this “damage” to the injured tendon will stimulate the healing process. This treatment still needs more research to find out how effective it is in treating hamstring tendonitis.
Surgery for Hamstring tendinitis
If there is no improvement in your symptoms after 3 months of physiotherapy treatment, surgery may be an option for your hamstring tendinopathy. Depending on the degree of damage to your hamstring tendon there are two surgical options: debridement or complete tenotomy.
Debridement
In this procedure the surgeon will cut away the injured parts of the tendon arthroscopically. Rehabilitation after this operation is crucial to strengthen the healthy parts of the tendon and promote healing.
Complete tenotomy
Also called a tendon release, the surgeon will cut through the tendon and reattach it to the bone. This option should only be a last resort, because recovery after a tendon release takes at least 3 to 4 months. Physiotherapy treatment after this surgery involves modifying your activities directly afterwards to allow the tendon to heal and strengthening the hamstring muscles to prevent reinjury.
What else could your Hamstring pain be?
Pain over your buttocks (The top tendon)
- Sciatic nerve irritation – More of a burning pain and referred pain into your thigh
- Piriformis Syndrome – You will feel a deep buttock pain with pins & needles or numbness with strenuous activities
- Ischial Bursitis – Pain over your “sitting bones” with direct pressure
- Gluteal muscle strain – You will have pain directly over your buttock that gets worse when moving your leg backwards or to the side
- Hamstring muscle tear – With a muscle tear your pain will be in the muscles at the back of your thigh and you might also have bruising
- Adductor Brevis tendinitis – Pain will get worse when you squeeze your legs together
- Hamstring Contusion – Bruising over your hamstring after a direct blow or fall
- See other types of hamstring injuries
Pain at the bottom tendons (behind the knee)
- Iliotibial band Syndrome (ITB) – Pain will be directly on the outside or your knee
- Knee Tendinitis – Your pain will be more to the front of the knee, above or below your kneecap
- Pes anserine bursitis – This is an inflammatory pain, thus red, hot or swollen at times and tender to the touch
- Gastrocnemius muscle strain – You will have loss of strength during a heel raise (standing on your toes) and pain on full stretch
- Popliteal nerve irritation– A burning sensation at the back of your knee
- Knee ligament injuries – An feeling of an “unstable” knee with pain radiating deep inside the knee joint
However, it is advised that you contact us when experiencing any of these symptoms. We can do a full assessment to distinguish between the different conditions to determine your diagnosis and give you a plan forward to get you active again!
Also known as:
- Hamstring tendonitis
- Pulled hamstring tendon
- Hamstring tendinopathy
- Injured hamstring tendon
