Updated: May 26
With proximal or high hamstring tendinopathy, prevention is definitely better than cure! In this article I’ll share 5 tips that may help you to avoid this injury.
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In this article:
Quick recap on what causes high hamstring tendinopathy
5 Tips for avoiding high hamstring tendinopathy
I also discussed it in this video:
Quick recap on what causes high hamstring tendinopathy
High hamstring tendinopathy develops as a result of mechanical overload of the proximal (high) hamstring tendon where it attaches onto the ischial tuberosity (sit-bone). Tendons are extremely strong structures and are very good at handling tensile forces (think of this type of force as a pulling force along the length of the tendon). However, they don’t seem to like compression forces as much and compression usually plays a major part in the cause of high hamstring tendinopathy.
When analysing what caused the mechanical overload of the hamstring tendon, it is usually that:
the tendon was asked to absorb large forces in a position where it was compressed over the sit-bone (positions that involve a lot of forward hip flexion) and
the tendon was either not prepared for these forces (not strong enough) or
the forces just occurred too often (not allowing it to recover properly).
doing a lot of hill running where the hip is flexed up high (tendon compresses on sit-bone) and you forcefully contract the hamstring to get you up the hill or doing lots of heavy squats and lunges;
doing lots of deep static hamstring stretching is another common cause for this condition;
and possibly one of the most frustrating scenarios (because you didn’t actually “do” anything) is when people compress the tendon for long periods by sitting on hard surfaces, often increasing the compression by leaning forward to chat to someone.
Tips for preventing High Hamstring Tendinopathy in runners
You may notice that the things I listed above are all activities that millions of people do on a daily basis and it doesn’t cause them any problems. So why do these activities sometimes lead to people developing high hamstring tendinopathy?
It is all about tendon overload. We can condition our tendons to withstand different levels of tensile and compression forces. If the load that you are putting through your tendon is a lot more that what it is used to or prepared for, it can cause a tendinopathy to develop. Sometimes the load that appears to have caused the injury may not even have been that high – it may just be that you did too much of that activity too often and you've not given your tendon enough time to recover (in other words the cumulative load over several sessions were too high).
TIP 1: Monitor your levels of fatigue and recovery
This is an extremely important aspect of injury prevention. Exercise of any form causes micro-trauma in all structures in your body, including your tendons. This micro-trauma is normal. It stimulates the hamstring tendon to produce new and stronger collagen fibres and by repairing the micro-trauma it grows stronger over time.
If, however, you do another hard training session before your hamstring tendon has fully repaired itself, the micro-trauma may accumulate and your tendon can go into a state of disrepair, causing a tendinopathy. That’s why allowing enough recovery time between training sessions and balancing your high and low intensity sessions are so important.
How quickly your body can repair itself after exercise depends on a whole host of things but some of the most important ones include:
how much it has to do – harder exercise causes more micro-trauma,
your training status – well-trained people recover more quickly,
nutrition – your body needs the right nutrients to build new cells,
your level of mental and physical fatigue can also heavily affect recovery rates,
And then there are factors like the menopause and older age that can slow down recovery. This means that you may have to make adjustments to your training programme as you get older to accommodate this.
TIP 2: Avoid sudden large increases in workload
Our tendons, including the hamstring tendon, can adapt to handle nearly any load if you train it to do so through progressive overload. Progressive overload means that you exercise a tendon a little harder than what it’s used to. This will cause the tendon to remodel itself over time and to become stronger so that it can easily handle that exercise load. Once it’s used to that load, you can then increase it again so that it’s a bit more than what the tendon is used to.
The important thing to notice with this process is that you only use small increases in training load, but that when you look back over a few months you’ll notice that you’ve actually made big gains in strength.
The problem with sudden large increases in training load (in a short period of time e.g. a couple of weeks) is that it doesn’t allow the tendon enough time to recover and repair itself, which can cause it to go into a state of disrepair as mentioned in Tip 1.
For runners, the types of training that places the highest work load on the hamstring tendon include fast running and hill runs. Make sure that you keep an eye on how you schedule these in your training plan.
TIP 3: Decrease over-stride
Some runners may over-stride when they run and land with their heel far in front of their body. This position can potentially load the hamstring tendon more. You can improve over-striding by trying to land with your foot closer to your body and increasing you step rate slightly.
TIP 4: Avoid deep static hamstring stretches
Yoga can be a great form of exercise, but I’ve actually had several patients where deep hamstring stretches in yoga had caused their hamstring tendinopathy. Ironically these patients have often been runners who had started yoga as they felt they needed to improve their flexibility to help prevent injuries.
Using active stretches, where you move in and out of a position may be a better option.
TIP 5: Watch what you sit on
Please don’t interpret this as sitting is bad for you – it’s not and it’s a very normal thing to do. The only time that you may want to be weary of it is when you’re sitting on a very hard surface (think pub bench without a cushion) and leaning forward (likely to chat to a mate above the noise). This scenario will cause the hamstring tendon to compress in 2 ways:
The bench will likely squash it against your sit-bone and;
as you lean forward in a sitting position, you increase your hip flexion and that will also compress the tendon against the bone.
Sitting like this for a short period of time may be absolutely fine, but doing it for a few hours may be more than what the tendon is happy to handle.
Need more help with your injury? You’re welcome to consult one of the team at SIP online via video call for an assessment of your injury and a tailored treatment plan.
About the Author
Barton, C. J., et al. (2016). "Running retraining to treat lower limb injuries: a mixed-methods study of current evidence synthesised with expert opinion." British Journal of Sports Medicine 50(9): 513-526.