Hamstring Tendinosis

hamstring images 2Hamstring injuries are very common injuries and healing them can be more difficult than you might think.

Whatever the ‘grade’ of the injury, once you injure your hamstring it’s almost impossible to fully heal because most types of movement that utilize the hamstring can easily re-injure the area. In most cases, it’s just not possible to stop everything and rest your hamstring properly, but everyday activities (especially training activities) can actually prevent the strained/stretched hamstring from healing properly. People don’t realize that even after the pain goes away your hamstring isn’t fully healed. With constant use, you run the risk of re-injury and prolonged healing time.  Ultimately you can risk permanent damage. The more active we remain, the more we prevent the hamstring muscles from healing completely. If we continue to re-injure the area through our daily activities, this can often lead to chronic hamstring pain and hip immobility.

Tendinitis is the inflammation or irritation of a tendon. Hamstring tendinitis is most often caused by overuse, which, as we know, is a ‘too-much-too-soon’ syndrome.  Because tendinitis is more of an ‘acute’ inflammatory condition, we can’t really have ‘chronic’ tendinitis.  If we continue to experience the symptoms of tendinitis beyond the ‘acute’ and ‘subacute’ phase, it’s probably becoming, or has become tendinosis.

Tendons have only a limited capacity to become inflamed. Over time the swelling/inflammation goes away but you are still likely to have pain from the repeated scarring of the tendon. In these chronic cases, we refer to it as a tendinosis…a degenerative progression of the original tendinitis.

Tendinosis, involves a partial loss of the tendon’s blood supply and weakening of the tendon, leaving it even more susceptible to injury. With tendinosis, the natural healing process of a tendinitis has been disrupted, and is no longer working.  The tendon actually undergoes a structural change from the chronic stress, and is characterized by a degeneration (and not inflammation) of the tendon.   More specifically, tendinosis is characterized by a degeneration of the fibrous material known as collagen, from which tendons are made.  ‘Itis’-types of treatment do little for tendinosis.

Tendinosis actually requires a two-prong approach. One, requires us to heal the tendinosis. The other, requires us to discover/treat the cause of the inury; overuse, over-training, movement impairment syndrome, malalignment syndrome, dysfunctional movement pattern, etc.  Based on our understanding of ‘pain’ and how it affects movement patterns through the CNS, as well as the negative effect of ‘continued/too much activity’, it would seem difficult to correct the ‘cause’ without first healing the tendinosis, but a combination of tendinosis treatment and corrective exercise might be a very effective approach, as long as you don’t prolong the injury and/or re-injure the hamstring from too much activity.

People suffering from hamstring tendinosis will likely have pain where the hamstrings attach to the ischial tuberosity (the bones that you sit on).  This pain can eventually spread down into the muscle belly, and toward the knee. It is important to first identify and treat adhesions within the surrounding hip musculature.  This will work to ensure that the hamstring is not being forced to handle excessive loads. In order for the hamstring to be allowed to heal it is important to decrease the load/strain that the hamstring is placed under. Then, in order to heal the tendinosis, you must treat the scar tissue and improve the blood flow to the area.

If you are a runner or cyclist, you most likely need to temporarily trade running/biking for other fitness or corrective exercises that will not re-injure or prolong the healing process.  To give the hamstring a chance to heal, it can take up to 12 weeks off from the offending activity.

Once hamstring tendinosis is correctly diagnosed, you can help cut down on the recovery time by improving tissue quality and blood flow to the injured area.  For healing the tendinosis, eccentric strengthening (negatives) of the hamstring is more effective than concentric work. With tendinosis, treatment requires some level of stress (more aggressive therapeutic treatment [not more activity] and resulting pain) to produce the proper remodeling effect and restart the natural healing process.  If there is no discomfort in an ‘osis’ tendon rehab program, you will need to up the stress a bit. Intensity will need to be increased.  With the proper amount of stress, some soreness should, and will ensue.  This discomfort should localize to the target tissue and can be painful to the touch, but there should be no swelling and no motion restriction.  This pain will follow a DOMS-like pattern and be gone in two or three days.

Tendinosis can also result from poor initial injury treatment, which includes:

1.  Becoming injured, but continuing to train through pain.

2.  Treating the symptom only, and failing to diagnose and treat the cause of the injury.

Many elite athletes use the ‘avoidance of injury’ as the measuring stick of success in their strength and conditioning and training programs, as opposed to quantitative physiological measures of capacity like power, strength, speed or endurance.  If you are training correctly, you are (or should be) definitely developing/improving your physiological capacities.  The General Adaptation Syndrome is a cause-and-effect no-brainer.  But, if you are injured, you can’t train effectively, compete, or even participate.  You cannot put fitness over pain or dysfunctional movement without introducing compensatory movement patterns that significantly increase the risk for injury!

Treating the tendinosis:  Discover and treat the cause of the injury.

  •   Screen, assess, evaluate, and treat
    •  Posture
    •  MMT (length, strength, stiffness)
    •  Malalignment Syndromes
    •  Iliosacral/Sacroilial Dysfunction
    •  Movement Impairment Syndromes
    •  Dysfunctional Movement Patterns
  •   Reduce training activity, to
    •  walking
    •  swimming
    •  corrective exercise if indicated (do not over do hamstring work)
  • Identify and treat adhesions within the surrounding hip musculature
    •  Strain-counter-strain
    •  Integrated neuromuscular inhibition
    •  Myofascial release
  •  Increase blood flow
    •   Heat
    •   Massage
  •  Remodel scar tissue
    •   Multi-directional friction
    •   Eccentric fiber realignment
    •   Maintain muscle extensibility/stretch tolerance
  •     Eccentric strengthening
    •   Isolytic METs
    •  Light/moderate resistance training
  • Correct dysfunctional movement patterns and rebuild the athlete:

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