Hamstring Tendinopathy – Everything you need to know!

Hamstring tendinopathy is a common condition that affects the tendon that connects the hamstring muscles to the pelvis, thigh bone, and knee. It is caused by repetitive strain on the tendon, often due to overuse, and can be associated with activities that involve running, jumping, and sudden stops and starts. 

The recovery process for hamstring tendinopathy can be challenging and may take several months. However, with proper treatment and a structured rehabilitation program, patients can expect to make a full recovery and return to their previous level of function. 

The first step in the recovery process for hamstring tendinopathy is to address the underlying cause of the condition. This may involve identifying and modifying any aggravating factors, such as overtraining, improper technique, or inadequate warm-up and cool-down routines. It may also involve the use of non-steroidal anti-inflammatory drugs (NSAIDs) or even corticosteroid injections to manage pain and inflammation. 

Once the underlying cause has been addressed, the focus of the rehabilitation program shifts to improving the strength, flexibility, and endurance of the hamstring muscles and the tendon. This is typically accomplished through a structured exercise program that includes a variety of exercises and modalities. One of the most important components of an effective rehabilitation program for hamstring tendinopathy is progressive tendon loading. This involves gradually increasing the load on the tendon over time to promote healing and improve the tendon’s ability to withstand stress. 

Research has shown that progressive tendon loading is an effective treatment for hamstring tendinopathy. A number of studies have explored the a 12-week rehabilitation program that included progressive tendon loading exercises, which led to significant improvements in pain, function, and patient satisfaction in individuals with chronic hamstring tendinopathy (see below for more details).

How to progressively load the tendon

There are several exercises and modalities that can be used to progressively load the hamstring tendon, including eccentric exercises, isometric exercises, and heavy slow resistance (HSR) training. 

Eccentric exercises involve lengthening the muscle while it is under tension, which has been shown to be particularly effective for hamstring tendinopathy. 

Isometric exercises involve holding the muscle in a static contraction, which can help improve muscle activation and strength. 

HSR training involves performing slow, controlled repetitions with heavy weights, which can improve the strength and endurance of the muscle and tendon. 

It is important to note that the progression of the rehabilitation program should be individualized and based on the patient’s symptoms, functional goals, and response to treatment. It is also important to ensure that the patient is performing the exercises with proper form and technique to avoid exacerbating the condition. 

Here is an example of a structured rehabilitation program for hamstring tendinopathy that includes specific exercises for progressive tendon loading: 

Phase 1: Pain Management and Symptom Control 

• Rest, ice, and anti-inflammatory medication as needed 
• Avoiding activities that aggravate the condition 
• Stretching exercises for the hamstring and surrounding muscles 
• Isometric hamstring contractions with the knee bent and straight 

Phase 2: Progressive Tendon Loading

• Eccentric hamstring exercises: Starting with 3 sets of 10 repetitions, increasing to 3 sets of 15 repetitions over 3-4 weeks. Examples include: 
  • Nordic hamstring curls: Slowly lowering the body from a kneeling position with the feet secured, and then using the arms to push back up. 

• • Single-leg Romanian deadlifts: Hinging forward at the hips with one foot lifted off the ground, then returning to a standing position.

• Isometric exercises: Holding for 10-30 seconds, starting with 3 sets and progressing to 5 sets over 2-3 weeks. Examples include: 
  • Isometric hamstring holds with a resistance band: Placing a resistance band around the ankle and pushing against it with the foot while holding a bridge position. 
  • Isometric hamstring holds with a Bench/Swiss ball: Placing the feet on a Swiss ball and lifting the hips into a bridge position, then holding while pressing the feet into the ball. 

• Heavy slow resistance training: Starting with 2 sets of 8 repetitions, progressing to 3 sets of 10 repetitions over 4-6 weeks. Examples include: 
  • Romanian deadlifts with a barbell or dumbbells: Lifting the weights slowly and lowering them even more slowly, emphasizing the eccentric phase. 
  • Leg press with heavy weights and slow repetitions: Lowering the weight slowly and pushing it back up with a controlled tempo. 

Phase 3: Functional Rehabilitation 

• Plyometric exercises for power and agility: Starting with low-intensity exercises and gradually increasing the intensity over several weeks. Examples include: 
  • Box jumps with a low box and landing softly on the balls of the feet. 
  • Jumping lunges with a soft landing and controlled knee bend. 

• Sport-specific drills and activities: Gradually reintroducing the patient to their sport or activity, with a focus on proper technique and gradual progression. 

It’s important to note that this is just an example of a structured rehabilitation program, and the specifics of the program should be tailored to the individual needs and goals of the patient. It’s always best to work with your physiotherapist to develop a personalized treatment plan. 

What level of discomfort is acceptable?

When recovering from hamstring tendinopathy and working through a progressive loaded program, it’s important to understand that some level of discomfort during exercise is normal and even expected. However, it’s important to distinguish between discomfort and pain. Discomfort may be felt as a mild ache or stiffness in the affected area, but should not be sharp or intense. This discomfort threshold can vary from person to person, and it’s important to work within one’s own pain tolerance to prevent further injury. In general, a 3-4 out of 10 level of discomfort is acceptable during the exercise program for progressive tendon loading. This means that the discomfort should not increase after the exercise, and should not interfere with daily activities. 

Patients should communicate with their Physiotherapist about their discomfort level and adjust the program as needed to avoid pain and promote healing. By staying within a safe discomfort threshold, patients can safely and effectively build capacity back in the tendon and achieve their recovery goals.

Managing flare ups

Flare-ups are common during the rehabilitation process for hamstring tendinopathy, and it’s important to know how to manage them to prevent further injury and promote healing. Here are some guidelines for what to do if a flare-up occurs during each phase of the rehabilitation program we described above: 

Phase 1: Pain Management and Symptom Control 

• Rest the affected area and avoid any activities that aggravate the condition.
• Use ice or cold therapy to reduce pain and inflammation. 
• Take anti-inflammatory medication as prescribed by a healthcare professional. 
• Stretching exercises should be performed with caution and within the patient’s pain threshold.
• Isometric exercises can be continued as long as they do not increase pain. 

Phase 2: Progressive Tendon Loading

• Modify the exercise program to reduce the load on the affected area, such as reducing the weight or repetitions. 
• Slow down the progression of the exercise program, such as performing the same exercises for an additional week or two before advancing. 
• Focus on the eccentric phase of the exercise, which has been shown to be effective in reducing pain and promoting healing.
• Consider adding isometric exercises to the program if they do not increase pain. 

Phase 3: Functional Rehabilitation

• Modify the plyometric exercises to reduce the impact or intensity, such as performing them on a softer surface or with a lower box.
• Consider returning to a previous phase of the program and working back up to the flare-up level.
• Focus on sport-specific drills that do not aggravate the condition. 

It’s important to listen to the body and not push through the pain, as this can exacerbate the condition and prolong the healing process. By taking a step back and modifying the exercise program, patients can reduce pain, promote healing, and continue the path to recovery. 

The Evidence

There have been several studies published on the use of progressive tendon loading in the rehabilitation of hamstring tendinopathy, one of which was conducted by Visnes et al. (2011) and published in the Journal of Orthopaedic & Sports Physical Therapy. This study describes a 12-week rehabilitation program for athletes with chronic hamstring tendinopathy that includes eccentric hamstring exercises and progressive tendon loading.

The program was divided into three phases, with each phase increasing the load on the hamstring tendon. During the first phase, the focus was on isometric hamstring exercises, with the aim of gradually increasing the load on the tendon without causing pain. In the second phase, the exercises progressed to eccentric hamstring exercises, with the load gradually increased over time. Finally, in the third phase, the exercises were more functional in nature, with the focus on sport-specific activities such as running and jumping. 

The study found that the progressive tendon loading program was effective in improving hamstring strength and reducing pain in athletes with chronic hamstring tendinopathy. In addition, the athletes’ hamstring muscles showed an increase in size and improved morphology following the 12-week program. 

Progressive tendon loading is a key approach for many muscle related injuries apart from tendinopathies’, where the principles of this method are shown to be highly effective. One study that is often cited in relation to progressive tendon loading is the research by Rio et al. (2016). Although this study focuses on groin pain, it includes a progressive tendon loading program that is applicable to hamstring tendinopathy.

In this study, Rio et al. developed a 12-week rehabilitation program that included progressive tendon loading exercises for the adductors and hip muscles. The program was divided into three phases, with each phase building on the previous one to progressively increase the load on the tendons. The study found that the progressive tendon loading program was effective in reducing pain and improving function in athletes with adductor-related groin pain. While this study is not specific to hamstring tendinopathy, the principles of progressive tendon loading can be applied to various tendinopathies, including hamstring tendinopathy. 

Another study specifically focused on hamstring tendinopathy that includes a progressive tendon loading program was by Malliaropoulos et. al. (2012) where the authors describe a 12-week rehabilitation program for hamstring tendinopathy that includes progressive tendon loading exercises. The program is divided into three phases, with each phase gradually increasing the load on the hamstring tendon. The exercises include isometric contractions, concentric and eccentric hamstring exercises, and functional exercises. The authors found that the program was effective in reducing pain and improving function in athletes with hamstring tendinopathy. 

Studies like these along with numerous others provides evidence-based practice for the use of a progressive tendon loading program in the rehabilitation of hamstring tendinopathy, , and demonstrates the potential long-term benefits of this approach. Studies like these are a useful reference for healthcare professionals and physiotherapists who are developing treatment plans for patients with hamstring tendinopathy, and there principles should be utilised when developing treatment plans for patients with this condition.

In summary, hamstring tendinopathies can be a challenging condition to recover from, but with proper treatment and a structured rehabilitation program that includes progressive tendon loading exercises, patients can expect to make a full recovery and return to their previous level of function. It is important to work closely with a healthcare professional to develop an individualised treatment plan that is tailored to the patient’s specific needs and goals. 

Reference: 

• Rio, E., Kidgell, D., Purdam, C., Gaida, J., Moseley, G. L., Pearce, A. J., & Cook, J. (2016). The effectiveness of a rehabilitation program to treat adductor-related groin pain in athletes: A randomized controlled trial. The American Journal of Sports Medicine, 44(4), 937-947. doi: 10.1177/0363546515621554 
• Malliaropoulos, N., Papacostas, E., Kiritsi, O., Papalada, A., Gougoulias, N., & Maffulli, N. (2012). Posterior thigh muscle injuries in elite track and field athletes. The American Journal of Sports Medicine, 40(1), 181-188. doi: 10.1177/0363546511423389
• Visnes, H., Bahr, R., & Holm, I. (2011). Influence of exercise mode and concentric hamstring strength on hamstring eccentric strength and unilateral hamstring to quadriceps strength ratios. Journal of Orthopaedic & Sports Physical Therapy, 41(4), 242-249. doi: 10.2519/jospt.2011.3444