Hamstring Pain in Runners

With Spring approaching and hopefully warmer weather on the way, many of you will be ramping up your training for some Summer Running events. I have recently had a few patients come in who have been limited in their training by hamstring pain and were stuck because, despite rest and some treatments, they have not been able to get back to running the way they want. This article will talk about hamstring pain and offer some advice on how to get over it and back to running pain free....

Hamstring pain can really be divided into two types: In the first, the pain is experienced in the main bulk of the hamstring-mainly in the middle part. This usually comes on more acutely/suddenly during a run in which you may be doing some speed work. Management of this type of hamstring injury is a bit easier than the next type and I described general guidelines is a blog I previously wrote here: www.promotiongb.com/blog/early-vs-delayed-rehab-for-acute-muscle-injury 

The second type of hamstring pain is proximal hamstring tendinopathy (PHT) and this can be a bit harder to get rid of and longer lasting. In most cases, it is brought on with training errors such as increasing volume or intensity too quickly, particularly the sudden introduction of sprinting, lunging, hurdles, or hills. Symptoms can also occur due to excessive use of static stretches, for example, yoga and Pilates postures that involve end range hip flexion. PHT will be the focus of this article as it seems to be the type that people have a harder time recovering from. The points I will outline are from a clinical commentary article by Goom et al. 2016.

The first thing that needs to be done if you have been struggling with pain in the Hamstring is to get a thorough assessment of your problem to make sure that it is truly a hamstring problem. Pain that is felt in the hamstring can be also be caused by multiple source outside the hamstring and you would hate to waste your time resting and treating an area that is not the source of your pain. 

Secondly, although it seems intuitive that if a muscle is sore and tight, you should stretch it out. However,  this is not something you want to be dong with PHT. The pain in the tendon can be aggravated by compression where it wraps around your sit bone (see picture above). Stretching usually adds more compression. The same can be said for foam rolling. If you have been doing this-stop! You are likely just adding more compression to a sensitive tissue. 

If you have pain high up in the hamstring that has just come on recently, backing off on some of your training and resting the area may be useful. However, if you have had these symptoms for a longer time, further rest may not be what the tendon needs. Resting may make it feel better, but when running or other exercise is re-initiated, the pain just comes back, leading you to become more frustrated. What is more important in these situations is that you progressively start loading the hamstring and tendon. The remainder of this article will outline some basic principles. However, everyone is different and it is imperative that the exercises are matched to the stage of your condition and you are educated in how to know what symptoms are ok and how to progress or regress your program based on what you are feeling. 

In the first phase of loading your painful tissue, we want to make the hamstring work, but also want to minimize compression of the tendon on your sit bone. This is accomplished with exercises that minimize movement through the hamstring (isometrics) and keep the hip in a more straightened position. See Figure 2 for some examples of exercises. Again, knowing what is ok to feel while and after  you are doing these is very important so that you do not do too much or too little. 

Once you are dong well with Phase I exercises, the activities are progressed to add a bit more movement through the hamstring but again, the hip is kept more in a straightened position. Monitoring of symptoms during and after again is very important and this is where I spend a lot of time educating my patients with this type of problem. You need to know what is ok to feel and what isn't and how to progress or regress as needed. 

The 3rd Phase of the rehab progresses to mare challenging loading and involves the addition of more hip movement during the exercises. These are exercises that many people try to do right away, only to find that it make their symptoms a lot worse because they are implemented too early. However, with a gradual progression and the right education on how to progress, these exercises can eventually be done in order to prepare the hamstring for the demands of your sport. 

Other Considerations:
1. Ok to still run?: Throughout any rehab for an injured athlete, my goal is to keep them doing the things they enjoy. This rehab program is not always done in isolation when I work with runners. I want to allow you to keep running some and most people are able to do this with the right advice on how to change their running technique and/or time/mileage to allow running, but not at the expense of aggravating the tendon further. 

2. Passive Treatments?: Depending on who you see for treatment of your painful hamstring/tendon, you may receive dry needling, kinesiotape, instrument assisted soft tissue mobilization (IASTM, Grasten), or cupping. Although the evidence is lacking for the effectiveness of any of these treatments, they are done, and some people feel better for a short-term. The thing to remember however, is these treatments (like rest) do not prepare your muscle and tendon to handle what you want it to do when you feel "better." This results in the return of symptoms when you try getting back to running/exercising. 

---

I hope that this information is useful to you. This is not meant to be a prescriptive solution for your specific problem, but instead it is meant to educate you in evidence-based options for getting past hamstring or tendon pain and back to running the way you want.  As I have said throughout this article, appropriate education and guidance is needed as each individual's problem is different. 

If you or someone you know has been struggling with pain in the hamstring region, feel free to reach out to me and I would be happy to talk with you about your problem and possible solutions. 

Thanks for reading,
​Bob