One of the more common injuries I see in runners are chronic high hamstring tearing that results in HHT or High Hamstring Tendonosis at the attachment on the Ischial Tuberosity.  It is challenging for runners to understand how this happened and why it got progressively worse over time.  This article will attempt to explain this process, why it occurs and what you can potentially do about it once it is accurately diagnosed. Accurate diagnosis is imperative to effective treatment.

There are four hamstring muscles that attach on your Ischial Tuberosity and help to move your hip into extension as well as flex your knee.  The point of attachment for your hamstring muscles is the hamstring tendon.  Tendons attach muscle to bone and transmit the forces from the muscle for you to move the joint.  Overtime, such as with running the tendon is put under significant strain.  Any structure subjected to repetitive strain needs recovery time.  Added strain such as increased speed or running up hills will require even more recovery to withstand future strain. Unfortunately, many athletes and runners do not provide their tendons with adequate recovery.  This lack of recovery can lead to chronic weakening and damage to the tendon known as Tendinopathy or Tendonosis.

Because this process takes place gradually athletes and runners perceive their bodies early warning signals such as pain, tightness and discomfort as a normal part of training.  They often do socially acceptable self-treatment methods that appear to be helping them to continue training.  These include foam rolling, stretching, strengthening, massaging and taking Ibuprofen.  In other cases, they are consulting non-trained, non-experienced, ill-informed but perhaps well intentioned massage therapists, chiropractors, physical therapists and primary care doctors who are guiding them down a path to severe injury and sometimes irreparable damage.  While I understand the psychology of wanting to save money and avoid a trip to a specialist what I don’t understand is putting your wellbeing in the hands of someone who does not specialize in these types of injuries.

What is Tendonosis?

Tendinosis, sometimes called chronic tendinitis, chronic tendinopathy, or chronic tendon injury, is damage to a tendon at a cellular level (the suffix “osis” implies a pathology of chronic degeneration without inflammation).

What causes Tendonosis?

Poor posture and form and/or lack of sufficient recovery during repeated movements can increase stress on the tendons and make tendonosis more likely.

Why is stretching “bad” for my hamstring?

Stretching is not necessarily bad for you.  However, over-stretching, which is common in our culture can place excessive strain on the tendons attachment and can pull the fibers away from the bone and cause micro-tearing.  If stretching is done correctly and with proper form it can be safe but is questionable as to whether or not it will help you PREVENT injury.

Why is strengthening bad for you?

Strengthening is not a bad thing.  Excessive strengthening without enough recovery will lead to injury.  All weightlifters know that if you stress your muscles enough AND follow that up with adequate recovery their body will grow and adapt to the increase stress making it stronger and more resistant to fatigue during future bouts of strain.  Many runners and athletes do not allow for ample recovery and this leads to injury.  Other problems that arise with strengthening are unsafe or high risk strengthening tactics and performing exercises that are not sport specific but instead subject their muscles and tendons to irregular strain.

How do I know if I have tendonitis or tendonosis?

It is unlikely that you would have chronic tendonitis.  If you have had high hamstring pain for a long period of time or repetitive bouts than you probably have tendonosis.  Remember tendonosis is degeneration of the tendon.  Runners with tendonosis will often report that running slower helps, running faster hurts more and running uphill make it hurt more.  Ultimately an MRI would be necessary to diagnose the actual extent of the damage to the tendon.  It has been my experience that sometimes patients have a tear in one of the hamstrings as well as tendonosis in the common tendon attachment on the ischial tuberosity.

If I have tendonosis what do I do about it?

Over the years I have developed an effective treatment strategy to fix the damaged and degenerated hamstring tendon (this protocol will have good results for any area suffering from tendonosis).

  1. It starts with an accurate diagnosis which is achieved through a thorough history, exam and possibly MRI.
  2. A one-time, well places Platelet Rich Plasma Therapy (PRP) injection into the damaged area with a small diameter needle (opposed to a large diameter needle which can cause a puncture wound)
  3. 10 days of rest to allow the PRP to initiate your bodies natural healing response. This begins with inflammation for a few days followed by the second stage called the repair stage, During the repair stage your body will begin to send “builder cells” to the injected area and they will start repairing the tendon.
  4. During the Repair phase is is important to begin isometric strengthening to stimulate new tissue formation. This is coupled with Alter Gravity Treadmill rehabilitation to allow the tendon to strengthen in response to walking and running.  This is known as Sport Specific Training meaning the tendon will strengthen in response to specific stress.
  5. At about week 3-4 following the injection I progress you to concentric exercises. Concentric strengthening is known to stress the muscle versus the tendon.  This is coupled by increasing your weight on the Alter Gravity Treadmill to further stress the tendon but in a safe and controlled manner.
  6. At about week 5-6 I show you specific eccentric exercises. Eccentric strengthening is known to stress the tendon versus the muscle. This is important because at this point the tendon is ready to start being stimulated more and will strengthen in response to the eccentric training.  If done too soon the eccentric strengthening can cause damage.  The eccentric strengthening is coupled with increasing you weight and speed on the Alter Gravity Treadmill which will further strengthen the tendon specifically to running.
  7. Once you are running pain free on the Alter Gravity Treadmill we will begin to have you start doing short runs outside. Some studies indicate (so does my experience) that once a runner can run pain free at 90% their body weight the risk of re-injury is minimal.

So there you have it.  Of course there are always some exceptions but this is a general course of what you could expect from my clinic.  If you require further information email of call 858-268-8525

This article should not be confused as a substitute for an accurate diagnosis by a qualified doctor.