In Part #1 of our blog series on proximal hamstring tendinopathy (PHT), we defined what PHT is, potential causes and risk factors that can predispose you to develop it. In PHT part #2, we will introduce an evidence-based framework to help you deal with this pesky pain in the butt.
Researchers Goom et al have conveniently broken down a 4 stage approach to rehabilitating PHT based on the evidence they reviewed. They stress the importance of monitoring pain during the program and state that some pain is expected with the exercises but should resolve after 24 hours. The individual response of each individual patient will govern the progression of the proposed stages. For details please consult the reference, specifically figures 1-5 and work with your physiotherapist for guidance.
Stage 1 Exercises (Isometric Hamstring Load)
The first phase focusses on isometric (tightening the muscle without moving the limb) in positions that do not compress the PHT in order to load the muscle/tendon and reduce pain when it is irritated as it has been shown to have a pain-reducing effect. There should be a notable reduction in pain after these exercises when load testing the hamstring afterward. They also kept the hip in an almost neutral position (possibly 20-30 degrees of flexion) to minimize compression on the PHT.
- isometric leg curl
- bridge holds with hip neutral
- isometric straight-leg pull-down and trunk extensions.
Stage 2 Exercises (Isotonic Hamstring Load With Minimal Hip Flexion)
For stage 2, the authors used a heavy slow resistance (HSR) program including both concentric (muscle shortening against resistance) and eccentric (muscle lengthening against resistance) as this was documented to be easier to complete by patients. This type of exercise has been shown to be comparable in results to the widely accepted isolated eccentric exercise used in most tendinopathy rehabilitation programs. It was seen that HSR showed better collagen turnover in injured tendons than submaximal eccentric contractions. The focus with HSR is on slow, fatiguing, resisted movements starting at low resistance high reps and progressing to higher resistance and lower reps done every other day. The contractions are held for 3 seconds each for a total of 6 seconds. Loaded hip flexion is avoided to minimize compression on the PHT. Single-leg movements are also important to address asymmetrical loss.