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Our hamstrings are a group of three muscles in the back of our leg that originates at the ischial tuberosity (the bone we sit on) and has three separate attachments behind the knee. Proximal hamstring tendinopathy is when there is a deep localized pain at the ischial tuberosity that usually worsens after running, squatting, or prolonged sitting. This injury can be difficult to diagnose as there are many structures in the area, such as the sacroiliac joint or the sciatic nerve, that can cause similar symptoms.
This injury is most common in distance runners or sprinters because the hamstrings are responsible for decelerating the knee during swing phase of the running pattern. In other words, the hamstrings slow down and control knee extension as we advance our leg to the next step. The hamstring origin is under greater compressive stress when there is increased hip or trunk flexion. Examples of increased hip flexion include forward trunk lean, over-striding, or running uphill. Training errors can also lead to injury, specifically when increasing exercise volume or intensity too quickly.
Non-athletes can have proximal hamstring pain too as a result of prolonged sitting and more often occurs bilaterally. Postural deviations such as excessive anterior pelvic tilt or hip flexor tightness can increase stress at the hamstring insertion.
Now that we know what proximal hamstring tendinopathy is, let’s review some rehab exercises. When recovering from an injury, the key is to increase the load slowly. Pain should be mild and should not really exceed 3/10 during or after exercises and pain should subside within 24 hours.
Isometric Hamstring Load
An isometric contraction is where the muscle group is activated but does not move. A sub-maximal muscle contraction can inhibit pain. A bridge hold with neutral hip position is a good example of a hamstring isometric exercise.
Below, are pictures of two bridge variations.
The first bridge has the feet flat on the ground to provide a shorter lever. Next shown, is more difficult as the bridge is performed on the heels, creating a longer lever.
Hamstring Load with Minimal Hip Flexion
The goal here is to introduce load on the hamstrings with only minimal hip flexion in order to minimize compressive forces at the tendon. A single leg bridge (shown below), weighted bridges, and prone hamstring curls are good examples.
Performed just like a bridge however the body is propelled on one leg. Keep the other leg straight, in line with supporting leg.
Hamstring load with Greater Hip Flexion
Here the goal is to continue hamstring muscle strength while progressing into greater hip flexion. Exercises include step ups, walking lunges, deadlifts or hip thrusts (shown below).
The feet are flat on the floor, barbell is across the hips and shoulders are resting against the bench. Slowly lift the hips up and return to floor for repetitions.
Once the rehab has progressed to return to sport/running, increasing your running step rate will reduce stride length and hip flexion at foot strike thereby increasing gluteal activation and limiting hamstring stress. Additionally, improved core stabilization will limit anterior pelvic tilt, promote posterior pelvic tilt also reducing hamstring load.
