Injury Spotlight - Proximal Hamstring Tendinopathy

July 25th, 2020

Do you feel a pulling pain at the top of your hamstring/inner thigh when you stretch into a front split? Well you’re not alone. A proximal hamstring tendinopathy is one of the most common injuries when learning how to front split. But it can be a complex injury to understand!

This blog will break down why these injuries occur in simplest terms and leave you with a detailed understanding of why we can’t just leave these injuries to heal on their own! Let’s get started!

What is a Tendinopathy?

Unfortunately to fix this injury we need to start by understanding a bit about what a tendinopathy actually is! Hold tight whilst I explain a bit of the mumbo jumbo!

A tendinopathy is an umbrella term used to describe persistent tendon pain and loss of function related to loading (exercise). This terms covers both the pain and pathology that’s commonly associated with overuse and micro trauma of the tendons.

FIGURE 1: HAMSTRING TENDON

These injuries can be acute in nature, but generally speaking they tend to sneak up on a patient from repetitive microtrauma. Meaning that a patient rarely remembers any specific injury or event but might notice a niggle the next time they go to train. Failed healing of the microtrauma can occur in these tendons which leads to the formation of a tendinopathy. And that niggle can progress to pain overtime. 

The first thing I explain to my patients when it comes to tendon based injuries are that tendinopathies are incredibly misunderstood and frequently mistreated. In the past, rehab focused on stretching out these injuries and massaging them due to this sense of tightness, however as I’ll explain, this approach is actually quite detrimental to the tendon.

But for greater detail and insight on how tendinopathies actually occur, head to this little side blog (coming soon!) that explains tendons in more depth. This additional blog is relevant to all tendinopathies of the body, not just the hamstring.

Common Symptoms of a Proximal Hamstring Tendinopathy

A proximal hamstring tendinopathy usually presents with a deep localised pain high on the bony part of where the hamstring originates (just under your bottom crease) and can be aggravated from running, lunging, squatting, sitting and yes – the splits! When it’s quite irritated it can become a sharper pain.

FIGURE 2: HAMSTRING ANATOMY & TENDINOPATHY LOCATION

Anatomy

A bit more technical knowledge that’s relevant to our front splits - There are 3 hamstring muscles, that all share a tendon that attaches to the ischial tuberosity (pelvis). Semimembranosus appears to be the most common hamstring muscle affected in a proximal hamstring tendinopathy (Lempainen et al., 2015) and this muscle sits towards the medial/inside part of the hamstring next to the groin. I’ll explain why it’s important later on!

The Hamstring Tendon and the Front Split

So what is it about this position that makes the proximal hamstring tendon susceptible to injury? Well it’s all about the tensile and compressive load. Tendons are quite robust and strong but like any part of the body they can be susceptible to high forces.

FIGURE 3: TYPES OF FORCES

A tensile force lengthens the tendon whilst a compressive force leads to compression of the tendon. So the first thing we need to consider about a front split is it places a high amount of tensile force (stretch) through the front hamstring.

FIG 4: COMPRESSION ON THE ISCHIAL TUBEROSITY

The next thing to consider is that the hamstring tendon curves around the inferior portion of the ischial tuberosity (pelvis) and when we flex the hip the tendon compresses into this bone (Cook & Purdam, 2009). The greater the hip flexion angle, the higher the degree of compression. In addition to that, we can also have shearing forces when we rotate the pelvis but we will just focus on the first two forces in this blog.

So every time we front split, we are placing high amounts of tensile and compressive force through the hamstring tendon. Tendons that are gradually strengthened to handle this lengthened and compressed position will manage fine without issue. However, a tendon that isn’t strong enough to handle this force may begin to break down and commence the tendinopathy process.

Analogy Time - The Tug Boat and the Rope

In simple terms a tendon and muscle action can be described as a rope and boat. The rope is your tendon and the boat your muscle. As the rope begins to age and get stressed from forces, it can begin to fray. And these frayed fibres become a bit useless in the pulling of the boat.

FIGURE 6: WHIPPING

FIGURE 5: FRAYED ROPE

We can however weave/whip the frayed fibres of the rope back into place to strengthen the tendon and prevent its breakdown. The rope gets bigger as a result & stronger to compensate for those frayed fibres. And well the stronger the rope, the more competent it is at handling higher loads and stretched positions. And this is the same for our tendons! The more we load them, the stronger they become & the easier they can handle high loads under stretch.

So why can’t I stretch or massage this injury out?

Because it will make it worse! The tendon may warm up as you’re stretching it and give this false sense of starting to feel better, but when you cool down it will stiffen right up and likely exacerbate the pain. By stretching/massaging the tendon you’re increasing compressive and tensile forces and therefore contributing to the microtrauma. 

This will considerably slow down your recovery. Not to mention will risk potential long-term irreversible damage to your tendon. So first thing first - stop stretching and massage the hamstring/tendon.

You also should not return to stretching until your therapist gives you the all clear. Ideally this should be when your tendon pathology can handle the compressive load of the stretch. And unfortunately this may take some time, but trust me when I say if you follow this process properly from the start you will save yourself months of heartache and yoyo (up and down) rehabilitation.

Complete rest is just as bad!

If you don’t use your tendon, you will lose the strength you’ve worked hard to gain. Strength is an incredibly important protective mechanism for your tendon, and 1-2+ weeks of rest will de-load your tendon and leave it in a worsened state. Instead of complete rest, modify your load to avoid aggravating activities and your physio will slowly guide you on how to build your tendon capacity with strengthening.

Treatment

So once our body starts to develop a tendinopathy there is only one successful way we can overcome it (and reduce the risk of it reoccurring) – strengthening. 

The catch is the tendon requires progressive loading. If you load it too much, too soon or in a compressed/lengthened position, you risk aggravating it further, but if you underload the tendon you risk not seeing any improvements at all and it can potentially deteriorate further. So it becomes a juggling act. Which is why it’s so important to see a skilled therapist to figure out the correct load for you. And the process of loading needs to be quite specific and followed through the entire way, otherwise you risk re-aggravation of the injury.

Strengthening guidelines published in 2016 for proximal hamstring tendinopathies (Goom et al., 2016) suggested the following phases:

• 
  

Phase I: Isometrics (static contractions)

• Phase II: Isotonics in low hip flexion angles

• Phase III: Isotonics in high hip flexion angles

• Phase IV: Plyometrics (jumping/hopping) and Running (if applicable) 

For pole dancers however I would suggest a Phase IV of isotonic/eccentric strengthening in extreme hip flexion angles that the general population cannot usually perform, These are the extreme angles that we usually perform in order to make our tricks look beautiful (aka a split or over split). As most pole dancers don’t require explosive jumping/running movements plyometric and running type movements should only be included in programs for athlete’s wanting to perform these activities.

Common issues with this injury

The most common issue I see is dancer becoming complacent with their rehab as the pain improves. Unfortunately, the level of pain a dancer experiences with this injury does not necessarily correlate to whether the injury has healed. I.e if you’re pain is a 0 out of 10 for most activities, this does not mean you’re in the clear yet. There can still be underlying tendon damage without pain.

And I cannot stress enough that this issue will not go away on its own. It takes lots of hard work, commitment and a therapist who understand the demands of your activities to match the load required. Strengthen the tendon to perform high hip movements under considerable load per phase III and IV to ensure the injury has fully resolved. 

Returning to stretching

Once your therapist’s program has been followed and they have confirmed full tendon strength has been regained, a gradual return to stretching can then begin. 

Square your splits! In the anatomy section above I alluded to the fact that semimembranosus is the most commonly affected tendon in this injury. Well when we are in an open front split this muscle is compressed and put on further stretch making it susceptible to a tendinopathy. This is the same for using an incorrect split technique. So make sure you take your time to work on squaring your hips to help reduce the risk of this injury occurring. 

FIGURE 10: CLOSED SPLIT

FIGURE 9: OPEN SPLIT

How long will this take me to recover?

Every injury is different, however the sooner you get onto this injury the less time it will take for you to recover and your prognosis and tendon structure is likely to be much better. It’s best however to set out with the expectation that this will likely take months of rehabilitation and not a few short weeks.

Take home messages

• Tendinopathies are complex injuries that won’t magically disappear without tailored progressive strengthening

• Building strength takes time but long-term outcomes will be favourable if you follow the correct rehabilitation process

• Rehab takes work – stick to it. Taking short cuts won’t work.

• Do not stretch or massage a tendon, particularly in the early stages of rehab

Wanting tailored guidance and rehabilitation for your tendinopathy?

Online telehealth appointments can be booked with the Pole Physio via our ‘Book Online’ page that can be found here. Assessment and tailored rehabilitation are provided in accordance with best practice and evidence-based treatment to help you unleash your 'poletential'. And If you haven’t caught up yet on my front split blogs - make sure you head to the links below to check them out.

Until next time, train safe. 

The Pole Physio

x 

References:

1. Lempainen, L., Johansson, K., Banke, I. J., et al. (2015). Expert opinion: diagnosis and treatment of proximal hamstring tendinopathy. Muscles Ligaments Tendons J, 5, 23-28.

2. Cook, J. L., & Purdam, C. R., (2009). Is tendon pathology a continuum? A pathology model to explain the clinical presentation of load-induced tendinopathy. British Journal of Sports Medicine, 43(6), 409-416.

3. Goom, T., Maliaras, P., Reiman, M., & Purdam, C. (2016). Proximal Hamstring Tendinopathy: Clinical Aspects of Assessment and Management. Journal of Orthopaedic & Sports Physical Therapy, 46(6), 483-493.
   

Disclaimer: This information and these exercises are not tailored to you as an individual and do not constitute as medical advice. If you have medical or injury concerns, then please individually consult with a medical professional.