Get together with any group of runners and sometimes, it’s like a convention of orthopedic experts. Many mile chasers will discuss long, complex-sounding conditions and treatment options, like orthotics and various braces. Injury veterans who have survived common running maladies, such as plantar fasciitis, sore knees, and shin splints, share their stories.
There is one injury, however, that is spoken about in whispers, often because the inflicted runner no longer makes it to the group runs or track workouts. This condition is known as hamstring tendinitis or high hamstring tendinopathy, and it refers to inflammation of the common origin of the three hamstring muscles. To most runners who have had it, it’s simply known as a literal pain in the rear.
The Role the Hamstring Plays in Running—and Why They’re Prone to Tendinopathy
Among their many functions, the hamstrings are responsible for propelling your body forward with every step. Three separate muscles actually make up the hamstrings, and they share the same origin at the bottom of the pelvis, but they all attach to different areas after crossing behind the knee joint.
More From Runner's World
To think of how the hamstrings work, think of your body as a car. Your quads would be the springs and your hamstrings would be the engine. Needless to say, like the engine of a car, more miles frequently means greater chance of the engine breaking down. Despite both the potential seriousness of hamstring tendinitis and its prevalence among runners, it is largely ignored in the orthopedic literature, with much greater attention focused on traumatic injuries of the hamstring.
In one of the few articles that investigates high hamstring tendinopathy in a runner, Michael Fredericson, M.D., sports medicine physiatrist at Standford Medicine, notes that the basic anatomy and function of the hamstring muscle complex predisposes it to running injury. That’s because the muscle group is largely composed of “fast-twitch” muscle fibers, capable of generating a high degree of tension on the tendon with every contraction, therefore, a great deal of tension is generated within the common tendon of the three muscles.
Additionally, while running, the hamstring muscle contracts while in a stretched or lengthened position as the leg strides out in front of the body. This forces the hamstring to begin contracting with the hamstring muscles and tendon already under significant tension from the stretch.
Functionally, the hamstring has three basic roles with running: slowing the striding leg down as it approaches the ground; extending the hip and propulsion of the body forward; and assisting the calf muscle as it helps to flex the knee joint.
How High Hamstring Tedinopathy Affects Runners
After seeing literally thousands of patients over the past 12 years in sports physical therapy, one fact has become very apparent: high hamstring tendinopathy is an injury common to runners and pretty unique to them. The condition is characterized by several factors, some of which are critical to the initial diagnosis and subsequent management of the condition.
The predisposing factor for many runners can be a known or unidentified level of sciatic nerve irritation. This nerve irritation can be caused by lower back dysfunction, overstretching of the nerves in the leg, or because of swelling in the area of the tendon.
In addition to his findings described above, Fredericson observed the inclusion of nerve and lower back irritation with the presentation of hamstring dysfunction in an elite runner. The initial introduction of tendon pain is often preceded by a sometimes subtle level of low back discomfort and radiating tingling, numbness, or pain in the back of the leg. This ensuing nerve irritation may weaken the hamstring muscle and leave the muscle and tendon vulnerable to injury.
So if you do feel that tingling, numbness, or pain in the back of the leg, pay attention.
What Hamstring Tendinitis Feels Like: A Case Study
Mary, at the time a 45-year-old runner and triathlete, has been unable to train for the New York City Marathon because of a pain in the butt and sit bone region. She works at a computer and frequently sits for six to eight hours a day. She will sometimes feel lower back pain that includes a sharp tingling down the back of her leg. She is able to run at a very slow place, but cannot complete her long runs or perform any speedwork due to pain at her sit bone.
As exhibited by Mary’s case, the injury is characterized by a deep pain at the site of the ischial tuberosity or “sit bone.” The condition begins with soreness after running, but progresses to pain with activity and often soreness with the direct pressure of sitting. In most cases, the pain comes on without any acute event but rather increases over time with continued running. As the runner can often have a history of lower back pain, the symptoms frequently include a radiating pain that crosses the knee, suggestive of nerve inflammation from the lower back.
After a longer period of high hamstring injury, changes in running gait are sometimes apparent as the runner begins to “ride” over the leg and not use the hamstring complex to propel the body forward.
Our Favorite Foam Rollers
How to Treat Hamstring Tendonitis
Treatment of the a high hamstring tendinopathy injury should initially address identification and treatment of any lower back involvement with a visit to an orthopedic surgeon or spine specialist. Once lower back pathology has been ruled out or treated, treatment of the high hamstring can begin. The important areas to address are strength of the hamstring, hip, and leg, flexibility, and soft-tissue mobilization of the tendon and hamstring. Because running is an aggravating factor and is likely preventing the healing process from beginning, it is best to find other means of cardiovascular exercise.
You can make several ergonomic changes to address lower back symptoms, including avoiding the slumped position, not sitting for longer than 15 to 20 minutes without a short standing break, and temporarily avoiding hamstring stretching to allow the sciatic nerve to heal. You should also begin an exercise program that emphasizes general leg strengthening and avoids direct hamstring exercise.
After a period of getting your hamstring back in working order (up to six weeks), more specific hamstring work can begin, as detailed in the included exercises below. Once hamstring strength is nearly equal, a light running program can be initiated.
How to Prevent Hamstring Tendonitis
Prevention of hamstring tendinitis mirror the later phases of the rehabilitation program. Those without any hamstring problems will benefit from maintaining or improving hamstring and leg strength and can incorporate direct hamstring work into the initial exercise program.
All phases of exercises, as detailed in the moves below, can be used. Another important factor in preventing high hamstring problems is avoiding excessive stress to the lower back.
The process of returning to running after an extended period of high hamstring tendinopathy can be a long one, but can be done successfully with a patient and thorough reconditioning program. As with any injury, early intervention is the key to minimizing time away from running.
Exercises to Help You Address High Hamstring Tendinopathy
The following exercises, stretches, and massages are all moves to incorporate into your routine and keep your hamstrings strong, but keep in mind that they are not meant to take the place of either an evaluation by a physician or a guided treatment program by a physical therapist.
How to use this list: Do these moves 3 to 4 days a week, with at least one day of rest in between. Follow the reps listed below for each exercise and do 1 to 4 sets of the moves. You’ll need a set of dumbbells and an exercise ball (towels that glide on the ground also work). You can also perform most of these moves as bodyweight exercises.
Glute Bridge
Lie faceup, knees bent, and feet planted on the floor. Drive through heels, contracting the glutes to send hips up toward the ceiling. Body should form a straight line from shoulders to knees. Lower back down slowly. Repeat. Do 10 to 15 reps.
Bulgarian Split Squat
Stand in front of a low bench or step, facing away from it. Place left toes on the bench so the foot is elevated two to four inches off the ground. Hop the front foot forward (proper distance may take some trial and error) until right ankle is directly below knee when you lower down into a full squat. Engage the core and glutes and lower down with control. Most of the weight should be in the front leg with the back primarily used for balance. Stop when back knee hovers just off the ground, or when you are as low as you feel comfortable. Drive through front foot and squeeze glutes as you stand back up, tall and centered over front leg. Repeat. Do 10 to 12 reps. Then switch sides.
Hamstring Curl With Exercise Ball
Lie faceup with heels on top of an exercise ball, knees over hips. Lift the pelvis into a glute bridge position. Extend legs, keeping knees soft as you fully extend. Then drive heels down to pull feet back toward glutes. Keep hips lifted. Repeat. Do 8 to 10 reps.
Deadlift
Start standing with feet hip-width apart and holding a pair of dumbbells. Send hips back to hinge at hips and lower the weights down in front of legs. Lower the weight as far as your flexibility allows. Keep back flat and neck neutral. Drive through feet to stand back up. Repeat. Do 8 to 10 reps.
Squat
Start standing with feet just wider than hip-width apart, toes pointed slightly out. Initiate the movement by sending hips back and down. Bend knees to lower down as far as possible with chest lifted in a controlled movement. Keep lower back neutral. Press through feet to stand back up. Repeat. Do 10 reps.
Hamstring Stretch
Lie faceup. Extend one leg straight up in the air, and gently draw toes toward forehead. Use a resistance band for more comfort.
Hamstring Massage
Sit on the floor and place the roller under thighs. Use hands to lift hips then roll from the knees to the glutes. To increase the pressure, cross right leg over left and roll one leg at time, turning left leg in and out. Repeat on right leg.
Ian McMahan is head athletic trainer at Active Care Physical Therapy in San Francisco and has worked with runners and endurance athletes of all ages and ability levels. He has a master’s degree in exercise physiology from the University of Maryland. Since having to walk half of his first 5K in college, he has run several marathons, including the Boston Marathon.
A sports medicine professional, Ian McMahan focuses on science and endurance performance topics. He lives in Northern California and has raced every type of bicycle, using that as his reason to own as many bikes as possible.
