Proximal Hamstring Tendinopathy (PHT): A Real Pain in the Butt

Do you have a dull ache deep in your buttocks after sitting or while running? Hamstring injuries are common among athletes, are difficult to treat, and often recur. Proximal hamstring tendinopathy (PHT) comes on slowly as a dull pain at the sit bones (ischial tuberosity). This intractable injury can be healed, but the solution may be counterintuitive.

Key takeaways:
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    Proximal hamstring tendinopathy (PHT) is a chronic and painful condition that affects many athletes.
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    Current treatment options include multi-modal physical therapy, injections, or surgery.
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    The first-line recommendation of physical therapists is eccentric tendon loading exercises.
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    Tendon loading induces the tendon to repair itself.
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    A comprehensive strength training program may promote repair and improve overall mobility.

Your activity level declines, your run times slide, and your VO2 max falls off a cliff. Is it a new cardiovascular issue? Overtraining syndrome? Simply an unavoidable part of aging? Or is there something else going on that can be fixed?

Proximal hamstring tendinopathy (PHT) can be debilitating and demoralizing. You may feel like it will never be possible to move freely, sprint, or even go for a jog ever again. The deep pain in your sit bones makes driving difficult and time at your desk unbearable. You may have tried stretching your hamstrings and glutes thinking this would help ease the soreness, but it only seems to get worse.

What is proximal hamstring tendinopathy (PHT)?

Affecting both athletes and non-athletes, PHT is pain in the buttocks that flares up with running, sitting or lunging. The condition is often associated with sprinting and endurance running, but people who do not participate in sports can develop PHT, too.

Brodie Sharpe is an online physiotherapist from Melbourne, Australia, and is the host of the 'Overcoming Proximal Hamstring Tendinopathy' podcast. As he explains on his podcast, "The pain is caused by an overload to the tendon that connects the hamstring to the ischial tuberosity (sit bone), commonly from a sudden increase in training volumes or prolonged sitting on firm surfaces.”

Causes of PHT

This chronic condition can be associated with certain risk factors, such as overuse, poor pelvic stability, weak hamstring muscles, or “lazy” gluteal muscles. Repetitively stretching and overloading the semimembranosus tendon is the most common root cause of PHT. "For runners and triathletes, speedwork is a big component in the development of PHT,” Sharpe says. “I always recommend athletes monitor their speed and workout intensities and avoid any abrupt changes.”

A Type I injury due to high-speed running can have a more rapid onset but also quicker recovery. On the other hand, Type II overstretching injuries tend to have a more insidious onset and slower return to the prior level of activity.

PHT diagnosis and treatment

If you suspect you might suffer from proximal hamstring tendinopathy, there are ways how you can diagnose it. If that's the case, you can discover possible treatment options discussed below.

How is PHT diagnosed?

Most people will not remember feeling a particular injury but will report a gradual worsening of pain deep in the buttocks and potentially radiating down the back of the thigh. Standing up after sitting for a prolonged period may bring on the pain, as may lunging or running. An experienced physical therapist can diagnose PHT by looking for pain worsening when the tendon is stretched across the sit bones. An MRI or ultrasound can be performed but may not be necessary. However, if an ultrasound is performed, data may be collected which can show progress as the athlete works toward a return to play.

PHT treatment options

In the early stages when pain is most acute, the focus is on reducing inflammation and restoring range of motion and mobility. Progression to the next phase of rehabilitation is considered when it is possible to walk and jog slowly without pain. During phase two, the athlete will work on strengthening the hamstring, increasing the range of motion, and lengthening the muscle. When the athlete can jog at 50% of maximum speed without pain, it is time to progress to the final phase, during which athletes work on strengthening and sport-specific agility skills.

"The idea with early management of PHT is to first establish what training loads or strength exercises the tendon can tolerate. This might require lowering your mileage or temporarily removing speed sessions. Every scenario is different and requires a tailored approach based on symptoms. Once symptoms have settled, a gradual build-up of training and rehabilitation will raise the tendon's capacity for healing."

Brodie Sharpe

Other treatments for PHT

While non-surgical treatments are successful, surgery is sometimes unavoidable with a complete tear. However, surgery should be approached with caution as a recent systematic review of randomized trials found physical therapy to be equivalent to surgery in the midterm and long term concerning pain, function, range of motion, tendon force, and quality of life. The authors suggest that surgery be reserved as a last resort after first trying tendon loading for at least 12 months.

Other interventions such as platelet-rich plasma (PRP) and shockwave therapy may induce tendon healing, but the literature is not settled regarding the effectiveness of these approaches. Shockwave therapy looks promising but overall, there is a lack of good-quality evidence. Corticosteroid injection may provide short-term relief and return to play, but longer-term outcomes are mixed.

Can PHT be prevented?

An interesting study of Japanese sprinters carefully recorded training programs throughout 24 seasons. The hamstring injury prevention program focused on increasing the quality of sprints and reducing the number of hamstring injuries recorded during supramaximal/maximal running speeds. However, the number of injuries during submaximal speeds increased, but not significantly.

Eccentric hamstring strengthening is an important component of any PHT rehab program. Eccentric exercise is any movement that puts the hamstring under a load while lengthening the muscle. According to Sharpe, “a favorite exercise for PHT recovery is the deadlift. This offers eccentric loading in a slow and controlled manner. However,” he continues, “a lot of PHT sufferers start deadlifts too heavy or progress too quickly which leads to symptoms flaring up. The idea is to modify the weight, repetitions, range of movement, and tempo of the deadlift to find the perfect conditions that foster healing."

Hamstring strengthening – why it's important?

While this may be counter-intuitive, the hamstring needs to be strengthened to recover from injury. Putting a load on the muscle stimulates the tendon to recover. Why does tendon loading work to restore tendon function? The process of tendon healing resembles other wounds, progressing through stages of inflammation, proliferation, and remodeling. The initial inflammatory stage takes about a week, then the proliferation and remodeling stages can take months to complete.

Managing inflammation after an injury is important, and it is the job of two different types of macrophages to help moderate: M1 (promotes inflammation) and M2 (sends anti-inflammatory signals). Although inflammation is a necessary function, an over-reaction could lead to poor outcomes. For this reason, corticosteroids may help in the short term to tamp down inflammation but may not be helpful over the long term if they disrupt the delicate balance between the M1 and M2 macrophages.

During the proliferation stage, macrophages help clean up damaged tissue and resident tendon fibroblasts get to work repairing the tendon. During the remodeling stage, which can last months, the fibroblasts continue to produce new cells, orient the fibers and crosslink collagens. PHT recovery is a long process, but it can be done.

Tendon healing remains a complicated topic with plenty of disagreements among experts who favor surgical intervention and those who believe a more conservative approach has better outcomes over the long term. Some tendons need to be protected and immobilized for a time after surgical repair, but others seem to benefit from movement and loading to preserve a range of motion and force during healing. The hamstring tendons seem to fall into the latter category, which is why a conservative approach with a knowledgeable physical therapist may well put you on the path to recovery.

A comprehensive strength training program will build better core support and recruit lazy gluteal muscles to help your hamstrings. As you begin running again you may find that you feel stronger than ever because your entire posterior chain is engaged with every step.

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