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BPC-157 is often marketed as a game-changing peptide for muscle repair, injury recovery, and athletic performance. But does the science back up these claims? And is it even safe or legal to use? In this article, we take a closer look at what BPC-157 is, why athletes are interested in it, and what the risks are. Remember, if you need help with an injury, you're welcome to consult one of our physios online via video call. In this article: What is BPC-157? Why do people use BPC-157? Does BPC-157 enhance athletic performance? Does BPC-157 speed up injury recovery? Is BPC-157 safe and legal? My recommendation How we can help 👉 We don't have total control over what ads are being shown on this page. If you see ads selling BPC-157 here,  follow the advice in this article and ignore them. What is BPC-157? BPC stands for “body protection compound”. It is a substance that occurs naturally in our gastric juices. It protects the stomach lining from stuff like alcohol, acid, and nonsteroidal anti-inflammatory drugs and helps to heal ulcers caused by these substances. BPC-157 is a peptide that scientists have derived from human gastric juices. In experiments  on various animal species (mostly rats), its healing properties have been shown to extend to various other tissue types, including muscles, tendons, and ligaments. It also acts as an anti-inflammatory in some of the animals on which it has been tested. Why do people use BPC-157? The healing and anti-inflammatory properties of BPC-157 in lab animals are thought to work in the same way in humans. So, it might enable athletes to recover faster from hard training sessions, which would enhance their performance in the long run. It might also help athletes to recover faster from injuries. BPC-157 has been dubbed “the Wolverine peptide” among some weightlifters due to their belief in its ability to speed up healing. Some medical professionals tout and prescribe BPC-157 as a treatment for various conditions and injuries, including gastric ulcers, irritable bowel syndrome (this sounds plausible, given the role of natural BPC in our stomachs), ligament, tendon, and joint injuries, and erectile dysfunction. ❓ But is there any evidence that BPC-157 actually works as expected in humans? Just because something works a certain way when tested on a rat does not mean it will work the same way in humans. Does BPC-157 enhance athletic performance? 💡 The answer is short and simple: We don’t know. No credible, published research has been done on whether BPC-157 helps athletes to perform better. Does BPC-157 speed up injury recovery? 💡 Again, the answer is: We don’t know.  Only two small pilot studies  have been done on humans thus far. One looked at the effect of BPC-157 on bladder pain (12 people) and the other looked at knee pain (16 people). In both studies, BPC-157 seemed to provide pain relief. However, we can’t draw any definitive conclusions from such small studies. Small sample sizes can make drugs look much more or less effective than what they really are. Is BPC-157 safe and legal? Safety 💡 We don’t know yet whether BPC-157 is safe for humans. No adverse effects were reported in the two studies on humans discussed above. But, as mentioned, those studies were much too small to really know whether it is safe. The U.S. Anti-Doping Agency  warns that “there is a concerning lack of published clinical trial data because studies appear to have been cancelled or stopped without any published conclusions”. Legality 💡 The use of BPC-157, either for sport or for medical treatment, is not legal in most countries. The World Anti-Doping Agency  (WADA) has declared it a prohibited substance as of 2022. In 2024, a 19-year-old American speed skater, Kamryn Lute, received a one-year ban  after using a supplement containing BPC-157 that was recommended by a medical provider. WADA does not state why it has banned BPC-157, but presumably there are concerns about the lack of research into its safety and the (also unresearched) possibility that it does indeed enhance athletic performance. As for medical use, BPC-157 may only be used for research purposes with special permission (as in the two pilot studies mentioned above) and may not be sold to the public or even prescribed by medical doctors, according to the U.S. Food & Drug Administration . It also has not been approved by the European Medicines Agency or any other major health regulator in other countries. However, it is freely available online, and sellers mostly target athletes and weightlifters. Certain medical practitioners are also quite open online about the fact that they prescribe it. My recommendation The mere lack of research into the safety of BPC-157 means that I won’t take it for either sport or medical reasons – the difference between useful and harmful often lies in getting the dosage right, and at this stage we’re flying blind. BPC-157 is so widely available that I doubt any pharmaceutical company would invest in the necessary research to prove or disprove its efficacy and safety, since they are unlikely to gain from it financially. The only way it might be done is if a group of researchers could convince a non-profit organisation to provide a grant. From an athlete’s perspective, I also won’t consider using it until it has been approved by anti-doping authorities. But I’m not holding my breath. How we can help Need 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. We're all UK Chartered Physiotherapists with Master’s Degrees related to Sports & Exercise Medicine or at least 10 years' experience in the field. But at Sports Injury Physio we don't just value qualifications; all of us also have a wealth of experience working with athletes across a broad variety of sports, ranging from recreationally active people to professional athletes. You can meet the team here . About the Author Maryke Louw is a chartered physiotherapist with more than 20 years' experience and a Master’s Degree in Sports Injury Management. Follow her on LinkedIn and ResearchGate . References DeFoor, M.T. and Dekker, T.J. (2025) “Injectable Therapeutic Peptides—An Adjunct to Regenerative Medicine and Sports Performance?” Arthroscopy: The Journal of Arthroscopic & Related Surgery 41(2): 150-152. Matek, D. et al. (2025) “Stable Gastric Pentadecapeptide BPC 157 as Therapy After Surgical Detachment of the Quadriceps Muscle from Its Attachments for Muscle-to-Bone Reattachment in Rats” Pharmaceutics 17(1): 119. Gwyer, D. et al. (2019) “Gastric pentadecapeptide body protection compound BPC 157 and its role in accelerating musculoskeletal soft tissue healing” Cell Tissue Res 377: 153-159. World Anti-Doping Agency (2021) “World Anti-Doping Code International Standard Prohibited List 2022” U.S. Food & Drug Administration (2023) “Certain Bulk Drug Substances for Use in Compounding that May Present Significant Safety Risks” Chuanyang Xu et al. (2020) “Preclinical safety evaluation of body protective compound-157, a potential drug for treating various wounds” Regulatory Toxicology and Pharmacology 114: 104665. Lee, E. et al. (2024) “Effect of BPC-157 on Symptoms in Patients with Interstitial Cystitis: A Pilot Study” Altern Ther Health Med 30(10): 12-17. U.S. Anti-Doping Agency (2020) “BPC-157: Experimental Peptide Prohibited”

Learn how blood flow restriction (BFR) training works, its benefits for athletes and injury rehab, and how to use it safely. This evidence-based guide explains the science, optimal cuff pressures, and how to reduce risks so you can build strength and muscle with lighter loads. Remember, if you need help with an injury, you're welcome to consult one of our physios online via video call. This article contains affiliate links. We might earn a small commission on sales at no extra cost to you. In this article: What is blood flow restriction training? Does it work for training in athletes? Does blood flow restriction training work as injury treatment? Putting blood flow restriction training into practice Blood flow restriction training safety and side effects How we can help What is blood flow restriction training?   Blood flow restriction (BFR) training involves wrapping a cuff or tourniquet around the top of a limb – so, between the heart and the muscle(s) you want to target during exercise – to inhibit blood flow. This causes blood to pool in the working muscle, so the muscle quickly runs low on oxygen  and waste products from exercise build up . In this low-oxygen state, the muscle tires much faster than usual, and this signals to your body to make the muscle stronger, even though the exercise itself is quite light. In short, BFR tricks the body into reacting as if you were lifting heavy weights  – making it a useful strategy to build strength and muscle with lighter loads. Does it work for training in athletes?   👍 Evidence from recent research indicates that BFR training is effective for uninjured athletes .   In a systematic review  of available research that compared the effect of normal training combined with BFR training versus just normal training: 7 out of 9 studies found that adding BFR led to significantly greater strength gains compared to normal training, and about half of the studies also reported increases in muscle size. Improvements in certain sport-specific performance measures (such as sprint speed or jump height) were observed in 3 of 4 studies that tested them.   A similar analysis  that crunched the numbers from 28 studies involving 542 athletes found that BFR training can produce small to large improvements in multiple fitness areas  – including strength, power, speed, and muscular endurance. In that analysis, strength measures improved the most, but even explosive power and sprint speed saw moderate improvements.   BFR training also tended to improve body composition by increasing muscle mass (and possibly reducing fat) – though it did not significantly change overall body weight in the short term. Because regular weight training also strengthens your ligaments, tendons, bones, and cartilage, athletes tend to mix things up by combining various training methods. What is notable is that these benefits are achieved with much lighter weights  than traditional training, which might allow you to train your muscles “hard” while reducing recovery time for your joints. 👉 But it’s important to understand that your joint cartilage and ligaments don’t benefit much from BFR training, so general weight training without BFR is still necessary if you want to strengthen these types of tissue.   💡 In practice, many athletes use BFR as a supplementary training tool – for example, doing low-load BFR sessions in addition to normal high-load workouts to maximize gain s. Does blood flow restriction training work as injury treatment?   BFR training has attracted a lot of interest in injury rehabilitation, because it might be particularly useful when working the injured tissues hard (using heavy weights) during rehab exercises might be painful or unsafe.   Below we look at the research on whether BFR can help with muscle and tendon injuries.   Muscle injuries After muscle injuries or surgeries, muscle atrophy (wasting) and weakness  are common problems. BFR training has been used in these situations to help rebuild muscle without over-stressing the injured area.   For example, following knee surgeries like ACL reconstruction, patients often lose significant thigh muscle mass. Studies have explored adding BFR to post-ACL surgery rehab exercises to combat this muscle loss. The results have been mixed but somewhat promising.   A recent review  of six research papers that focus on using BFR in ACL reconstruction rehab found a variety of outcomes – from almost no added benefit to a significant benefit. Blood flow restriction training can potentially turn low-load exercises (like the straight leg lift) used for muscle activation into muscle-building exercises. In the studies with the beneficial results, BFR allowed these post-surgery patients to perform gentle exercises (like straight leg raises or low-load knee extensions) and still get a strength benefit similar to heavier training in some cases. This can be invaluable early in rehab when the graft and joint are still healing and heavy lifting isn’t safe.   💡 Overall, while more research is needed, BFR might turn out to be a useful tool to speed up muscle recovery and return of strength after an injury , especially when traditional high-load training cannot be used.   Tendon injuries Rehabilitating tendon injuries (like Achilles tendinopathy or tendon ruptures) usually involves loading the tendon to encourage it to form more collagen cells, which is the main building block of tendons.   Traditionally, this is done with relatively heavy-load exercises, which not everyone can tolerate. The thinking around BFR training is that it might be an alternative or adjunct for tendon rehab, since it can provide a training effect on the muscle-tendon unit with lower loads.   A 2024 review  of studies on the effect of BFR training on both healthy and injured tendons found inconsistent results about the effect on the tendon itself. In other words, it’s still unclear whether BFR directly makes a healing tendon stronger or thicker any faster than normal rehab does.   However, the same review noted that several studies reported that adding BFR led to decreased pain, increased strength (muscle strength, i.e. they could lift more weights), and improved functional performance  in patients with tendinopathy or after tendon repair. For example, in cases of Achilles and patellar tendinopathy, patients doing BFR could perform low-load leg exercises that resulted in pain relief and functional improvements over a few weeks. The benefits of BFR for muscles seem well supported, but the evidence so far shows little to no benefit for tendon health or strength. 🤷‍♀️ At first glance, these results appear positive, but I wonder whether BFR could cause trouble in the longer term if used in this way for tendon rehab. Are you actually putting the injured tendon at increased risk if you increase the muscle strength at a significantly faster rate than the tendon strength? Could this lead to a scenario where, for instance, you ramp your Achilles loading activities and sport up too quickly because your muscles are strong and your pain has dropped significantly, and then you reinjure the tendon because it could not keep up? 👉 For this reason, I would wait for clearer evidence of positive effects on tendon health and strength before I start recommending BFR therapy to my patients who are recovering from tendon injuries. Putting blood flow restriction training into practice   How to do BFR training and how often? The optimal training parameters are still being studied, but some patterns have emerged. Let’s look at what got the best results in BFR training studies.   What type of cuff to use It is important to get the cuff tightness right (see further down) – too loose will be ineffective and too tight might be unsafe. So get yourself a set of cuffs with a pressure gauge. Here are some examples available on Amazon – all have cuffs for the arms and the legs.   The unit of pressure used is mmHg . It stands for “millimetres of mercury” and comes from old-fashioned pressure gauges – 1 mmHg  equals the pressure needed to push a column of mercury 1 millimetre high.   How much pressure to apply   👍 The safest way to get the correct pressure for your limb size and cuff type is to find your limb occlusion pressure (LOP)  – the minimum pressure to completely block to the blood flow to and from the limb – and then to apply a percentage of that pressure.   To find your LOP and optimal training pressure for a specific limb: inflate the cuff gradually while keeping the limb still keep an eye on the pressure gauge you will feel your pulse starting to throb in the limb, and then it will disappear the pressure reading when your pulse disappears is your LOP now deflate the cuff to the desired pressure in research studies, the best results for arms have been achieved between 40% and 50%  of LOP, and for legs it was between 60% and 80%  of LOP – legs need more pressure because the arteries are larger.   Some sanity checks for the correct pressure range: Correct tightness: You feel a firm squeeze and your muscles “pump up” quickly, with a strong burning sensation during exercise. Skin may turn slightly red or pink. Too tight: Tingling, numbness, sharp pain, or skin turning pale/blue. 🚨 Deflate immediately . Too loose: Minimal sensation, muscles don’t fatigue quickly, no “pumped” feeling in the muscle.   How long should a BFR training session be? Research studies  where the muscle was kept under restriction for about 10 minutes at a time  (for example, doing 4 sets of an exercise with short rest intervals while the cuff stays inflated) yielded the best results.   How often? A 2024 analysis  of BFR research noted that training programmes with a frequency of at least 3 BFR sessions per week  tended to produce better improvements in athletes. But this will depend on your fitness level, ability to recover, and what other training you're doing.   How many weeks? The same analysis found that programmes that lasted at least 6 weeks tended to yield better results. Blood flow restriction training safety and side effects   Is BFR training safe? When done properly in appropriate individuals, BFR is generally considered safe.   A systematic review  of BFR’s effects on various body systems found no serious detrimental effects on the cardiovascular, endocrine, or muscular systems. In fact, most of the reviewed studies reported either positive or neutral effects on things like blood pressure, nerve function, and hormone levels when BFR is used correctly.   That said, like any exercise technique, BFR isn’t completely risk-free. There have been rare cases of serious side effects   reported in the literature . For example, one rehab study on Achilles tendon rupture patients recorded two instances of re-rupture and one case of deep vein thrombosis (blood clot) in the BFR group.   🚨 To stay on the safe side, it is recommended that certain high-risk individuals avoid BFR training or only do it under medical supervision – for example, people with uncontrolled high blood pressure, vascular disorders, a history of deep vein thrombosis, or sickle cell disease.   More commonly, people might experience mild side effects such as discomfort or pain in the limb during BFR (the muscle burn can be quite intense), temporary numbness or tingling, superficial bruising or petechiae under the cuff, or slight dizziness if the cuffs are released too abruptly.   👉 The bottom line: BFR should feel challenging (muscles will burn and limbs will feel tight), but it should not cause sharp pain, numbness, or discoloration  – if it does, release the cuff. How we can help Need help with an 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. We're all UK Chartered Physiotherapists with Master’s Degrees related to Sports & Exercise Medicine or at least 10 years' experience in the field. But at Sports Injury Physio we don't just value qualifications; all of us also have a wealth of experience working with athletes across a broad variety of sports, ranging from recreationally active people to professional athletes. You can meet the team here . About the Author Maryke Louw is a chartered physiotherapist with more than 20 years' experience and a Master’s Degree in Sports Injury Management. Follow her on LinkedIn and ResearchGate . References Colapietro MA, Portnoff B, Miller SJ, Sebastianelli W, Vairo GL (2023). “ Effects of blood flow restriction training on clinical outcomes for patients with ACL reconstruction: a systematic review” Sports Health, 15(2): 260-273. Miller BC, Tirko AW, Shipe JM, Sumeriski OR, Moran K (2021). “ The systemic effects of blood flow restriction training: a systematic review” Int J Sports Phys Ther, 16(4): 978-990. Öberg S, von Schewelov L, Tengman E (2025). “ The impact of blood flow restriction training on tendon adaptation and tendon rehabilitation – a scoping review” BMC Musculoskelet Disord, 26: 503. Pignanelli C, Christiansen D, Burr JF (2021). “ Blood flow restriction training and the high-performance athlete: science to application” J Appl Physiol, 130(4): 1163-1170. Vergara IB, Puig-Diví A, Amestoy-Alonso B, Milà-Villarroel R. (2024). “ Effects of low-load blood flow restriction training in healthy adult tendons: A systematic review and meta-analysis” Journal of Bodywork and Movement Therapies 39: 13–23. Wortman RJ, Brown SM, Savage-Elliott I, Finley ZJ, Mulcahey MK (2021). “ Blood flow restriction training for athletes: a systematic review” Am J Sports Med, 49(7): 1938-1944. Yang K, Chee CS, Kahar JA, Kamalden TF, Li R, Qian S (2024). “ Effects of blood flow restriction training on physical fitness among athletes: a systematic review and meta-analysis” Sci Rep, 14: 16615.

Red light therapy can be effective for treating many sports injuries and supporting post-exercise recovery. But each type of tissue (e.g. muscles, tendons) responds better to slightly different settings. And if you overuse it, it can actually slow healing! Read on to learn the ins and outs of how to use red light therapy at home for best results. Remember, if you need help with an injury, you're welcome to consult one of our physios online via video call. This article contains affiliate links. We might earn a small commission on sales at no extra cost to you. In this article: How does red light therapy work? It’s not a silver bullet Red light therapy risks and dangers What type of red light therapy machine is best for home use? Red light therapy settings and dosage Tendon injuries Ligament injuries Muscle injuries Exercise recovery Download the Red Light Therapy Guide Final tips How we can help References We've also made a video about this: How does red light therapy work? Red light therapy works by stimulating mitochondria – the energy-producing structures in your cells – using wavelengths of red or near-infrared light. This increases the production of adenosine triphosphate (ATP), which fuels cellular repair. It also reduces inflammation, improves blood flow, and might reduce pain through changes in nerve activity and releasing endorphins. In practical terms, the people in the white lab coats (who call it "photobiomodulation") have found benefits in especially pain reduction  for certain types of injury, and speeding up healing for injuries closer to the surface . Studies  have also shown that red light therapy helps with post-exercise recovery. However, results vary depending on the wavelength, dose, timing, and the condition being treated (see below). Some studies have shown no effect , likely due to improper dosing or other treatment errors. It's not a silver bullet Red light therapy on its own isn't enough for injury recovery.   Hopefully it would be obvious to everyone that an uninjured person isn’t going to get stronger biceps by just using red light therapy on their upper arms while not doing a single bicep curl. It’s the same with a body part that has been weakened by an injury. Red light therapy works best when you combine it with a structured rehab plan, aimed at restoring the injured part's strength and endurance. 👉 So, while red light therapy has been shown to reduce pain and speed up healing, it doesn't actually strengthen tissue. For your injured body part to regain its full strength and endurance, you have to still follow a rehab plan that includes strengthening exercises. Red light therapy risks and dangers Red light therapy is low-risk when applied with proper dosage, timing, and precautions  – but like most treatments, it’s not risk-free. Most studies report no serious adverse effects, and it’s approved by health authorities like the USA’s FDA for various therapeutic uses. ⚠️ The main risk is overexposure. Delivering too much energy can reduce effectiveness due to the biphasic dose-response  – a phenomenon where too much light slows healing instead of helping it. Repeated overtreatment may also cause temporary fatigue, dizziness, or skin irritation. (See below for dosage recommendations.) Another concern is eye safety. Red and near-infrared light can damage the retina if you stare directly into a high-powered device, especially lasers. Always avoid direct eye exposure and use protective goggles if your device lacks built-in safety filters. Don't look directly into the light - red light therapy can damage your retina if you're using a high-powered device. People with photosensitivity, or those taking photosensitising medications, should consult a doctor first. Additionally, red light therapy should not be used without medical supervision over active cancers, thyroid glands, or infected wounds because it might promote growth of these unwanted tissues or bugs. Inflammation reduction: Good or bad? Red light therapy reduces inflammation. But inflammation plays a crucial role in the early stages of injury healing as well as recovery after hard exercise. 🤷 So, won’t red light therapy work against healing and recovery in this regard❓ Excessive or prolonged inflammation can actually be harmful and might delay recovery from an injury or from exercise. 👍 Red light therapy doesn’t eliminate inflammation altogether. Instead, it modulates it – dampening excessive or chronic inflammation while still allowing the essential early-phase inflammatory processes to occur. In a 2016 study , identical twins did a 12-week leg strengthening programme. One was given actual red light therapy on his quads after each strength session and the other was given “fake” red light therapy. The one who received the real therapy had bigger and stronger quads after the 12 weeks, even though he had less inflammation. However, some evidence suggests daily red light therapy over many weeks might blunt adaptation in strength gains – alternating treatment days and non-treatment days or taking a week off red light therapy, say, every three weeks is advisable for strength athletes. What type of red light therapy machine is best for home use? Three types of device are used for red light therapy: low-level lasers (LLLT), LEDs, and infrared heat lamps. 👍 Clinical research has historically focused on lasers , which deliver focused, coherent light that penetrates deeply. However, lasers are expensive, require professional handling, and are impractical for treating large areas (e.g. your quad muscles) at home. 👍 LED devices  have become increasingly common in research  and offer comparable benefits when used correctly. Unlike lasers, they emit non-coherent light, but can treat larger areas and are safe, affordable, and easy to use at home. Modern LED pads and panels are now used in clinical trials and often match or exceed laser effectiveness when treating injuries over large areas and/or that don’t require deep light penetration. 👎 Infrared heat lamps , on the other hand, are not supported by high-quality research. They produce heat, not targeted photobiomodulation effects, and are ineffective for cellular repair. Conclusion:  High-quality LED devices are the most practical and evidence-supported option for home use. Here are four examples of LED red light therapy machines for home use. All of them are able to deliver the settings and dosages recommended below. There are also hand-held red light therapy devices, which might be useful for targeted treatment, for example of injured tendons, but I could not find one that stated the irradiance (see below) and therefore I cannot recommend one with confidence. Red light therapy settings and dosage The correct settings and dosage are essential to get results from red light therapy. The four key parameters are: Wavelength (nm) : This determines how deeply the light penetrates. Red light (600–700 nm) is best for surface tissues like skin and the tendons in your hand. Near-infrared light (780–950 nm) is invisible to the naked eye – it penetrates deeper and is more effective for muscles, ligaments, and thicker tendons, or ones that are not close to the skin. Irradiance (milliWatt/cm²) : The light intensity at the skin's surface. It tells you how much power is delivered per square centimetre. A common target for soft tissue therapy is 15–30 mW/cm². The further the light source is from the skin, the weaker the irradiance when the light hits the skin. At an irradiance of more than 50 mW/cm² you start running the risk of overexposure and impaired healing. ⚠️ Very few red light therapy machine sellers on Amazon state the irradiance, so make sure you know what you’re getting in this regard if you buy a machine on Amazon or elsewhere. Exposure time (minutes) : How long the light is applied to a single treatment area. This time needs to be adjusted based on the irradiance to ensure an effective dose is delivered – the higher the irradiance, the shorter the time. (See below how to calculate this.) Energy dose (J/cm²) : This is how much total light energy is delivered per square centimetre during a session. It’s the result of the combination of light intensity (irradiance) and exposure time, and is what actually drives the biological effect. In various studies, the best effects were achieved within the range of 3–10 J/cm². How to calculate the energy dose Two steps: Convert irradiance from mW/cm² to W/cm² (1 mW = 0.001 W) Multiply this by time in seconds For example, to calculate the energy dose when the machine is set at an irradiance of 20 mW/cm² and you use it for 5 minutes over an area: 20 mW/cm² = 0.020 W/cm² Multiply this by (5 x 60) seconds So, 0.020 W/cm² x 300 seconds = 6 J/cm² If you have the irradiance and energy dose and you want to calculate the time , divide the energy dose by the irradiance (in W/cm²). For example, your irradiance setting is 20 mW/cm² and the energy dose is 5 J/cm². So: 5 J/cm² ÷ 0.020 W/cm² = 250 seconds = just over 4 minutes per treatment spot. 👉 If, like me, you feel your 🧠 brain wants to go on ✈️ vacation when you look at all of these numbers and calculations, download our Red Light Therapy cheat sheet here . It simplifies things a lot! Now, let’s see what are the best research-backed approaches for treating various types of injury at home with a red light therapy device, and then we’ll look at red light therapy for post-exercise recovery. Tendon injuries 〰️ Light Frequency (Wavelength) Effective range : 630–680 nm (red light)  and 780–860 nm (near-infrared light) Most commonly used in effective studies: 660 nm  (red) – shallow penetration, suitable for surface tendons 810–830 nm  (near-infrared) – deeper penetration for thicker tissues 💡 Light Intensity (Irradiance) Effective range : 5–50 mW/cm²  at tissue level 10–30 mW/cm² got the best results in research ⏱️ Energy Dose Effective dose range : 4–10 J/cm²  per session Most tendon studies use 5–8 J/cm² 📅 Number of Sessions Most research studies showing positive effects used: 2–3 sessions per week (do not do sessions on consecutive days) Total: 10–15 sessions  over 4–6 weeks Considerations Tendons are slow to heal  – longer treatment periods are justified. Target tissue depth  matters: Near-infrared is better for deeper tendons. Don’t exceed 10 J/cm² per session  at the tissue site unless guided by clinical data – higher doses may reduce effectiveness (the biphasic dose-response effect). Always follow device-specific calibration , as stated output may differ from actual irradiance at the skin. Red light therapy works best for tendon injuries when you combine it with a structured rehab plan. I don’t recommend red light therapy as a standalone treatment for tendon injuries such as Achilles tendonitis or tendinopathy. Research  has shown that it works best when combined with the recognised best treatment approach of relative rest and strengthening exercises . Ligament injuries 〰️ Light Frequency (Wavelength) Effective range : 630–680 nm (red light) and 780–860 nm (near-infrared light) Most commonly used in effective studies : 660 nm (red)  – effective for superficial ligaments (e.g. lateral ankle ligaments) 810–830 nm (near-infrared)  – for deeper ligaments (e.g. MCL in the knee) 💡 Light Intensity (Irradiance) Effective range : 10–30 mW/cm² at skin level Most ligament-focused protocols use 15–25 mW/cm² ⏱️ Energy Dose Effective dose : 5–8 J/cm² per session 📅 Number of Sessions Effective clinical protocols  generally follow: 3 sessions per week (not on consecutive days) Total treatment duration : 4–6 weeks Typical total sessions : 12–18 Considerations Like tendons, ligaments are slow to heal  – longer treatment periods are justified. Early treatment (within 72 hours) improves outcomes for acute sprains. Avoid overtreatment  (>10 J/cm² per spot) to prevent slowing the repair process. Eye safety is crucial , especially when treating ligaments near the face (e.g., jaw, cervical spine). Muscle injuries 〰️ Light Frequency (Wavelength) Effective range : 660–680 nm (red light)  and 800–850 nm (near-infrared light) Studies on muscle contusions and strains show better outcomes with near-infrared light  due to deeper penetration. Consider using 660 nm  or dual-wavelength protocols for more superficial injuries. 💡 Light Intensity (Irradiance) Muscle studies showing benefits generally used 20–25 mW/cm² . ⏱️ Energy Dose Effective dose : 4–10 J/cm² , with most studies using 6–8 J/cm² 📅 Number of Sessions Effective protocols for acute injuries typically follow: Daily or every other day  for the first 1–2 weeks (inflammation phase) Then taper to 2–3×/week, and not on consecutive days, through recovery phase Considerations Early intervention : Best results occur when therapy starts within 24–48 hours post-injury Avoid heating devices : Red light therapy should not generate heat – devices must stay in the low-power range Adjust for tissue depth : Near-infrared light (830 nm) is necessary for muscle belly and fascia injuries Treatment area : Cover the full injured region and slightly beyond margins to address inflammatory spread Exercise recovery Red light therapy can help with post exercise recovery by reducing fatigue, improving muscle repair, and shortening recovery time after intense training or competition, including endurance or strength-focused activity. 〰️ Light Frequency (Wavelength) Effective range : 630–680 nm (red)  and 800–860 nm (near-infrared) Near-infrared  penetrates deeper, especially helpful for large muscle groups (quads, glutes, hamstrings) Research studies often used 660 nm + 850 nm  together 💡 Light Intensity (Irradiance) Effective range : 15–50 mW/cm² Studies showing best results tend to use 20–30 mW/cm² ⏱️ Energy Dose Studies have found that the effective range is 3–8 J/cm² , depending on muscle size and depth 📅 Number and Timing of Sessions When to treat : Studies show greatest benefit when red light therapy is applied immediately after exercise  or within 30 minutes Considerations Avoid overtreatment : Doses >10 J/cm² per spot may reduce benefits Hydration and rest  still matter – red light therapy complements but doesn't replace core recovery practices Adaptation caution : Some evidence suggests daily red light therapy over many weeks might blunt adaptation in strength gains – alternating treatment days and non-treatment days or taking a week off red light therapy, say, every three weeks is advisable for strength athletes. Download the Red Light Therapy Guide 👉 We've simplified the advice in this article  into an easy-to-read table. You can download the guide as a pdf with all the recommended red light therapy settings and dosages  for tendon, ligament, and muscle injuries as well as for post-exercise recovery, by going to this page. Final tips For successful red light therapy at home: Stay consistent : Missed sessions reduce effectiveness. Use on clean, dry skin  for best absorption. Avoid sunscreen or lotion  on the treatment area before sessions. Check your device’s output : Ensure that the manufacturer lists actual irradiance (mW/cm²). And check the actual irradiance at skin level, not just the manufacturer specs. Use dual frequency treatment if you’re not sure how deep the tissue is that you want to treat. Keep a log : Track sessions and pain/recovery progress. How we can help 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. We're all UK Chartered Physiotherapists with Master’s Degrees related to Sports & Exercise Medicine or at least 10 years' experience in the field. But at Sports Injury Physio we don't just value qualifications; all of us also have a wealth of experience working with athletes across a broad variety of sports, ranging from recreationally active people to professional athletes. You can meet the team here . About the Author Maryke Louw is a chartered physiotherapist with more than 20 years' experience and a Master’s Degree in Sports Injury Management. Follow her on LinkedIn and ResearchGate . References Ailioaie LM, Litscher G. “Photobiomodulation and Sports: Results of a Narrative Review” Life. 2021; 11(12):1339 Bjordal JM, Lopes‑Martins RÁB, Joensen J, et al. “The efficacy of low‑level laser therapy for shoulder tendinopathy: a systematic review and meta‑analysis of randomized controlled trials” Physiother Res Int. 2014;19(4):154–167 Felician, Márcia Cristina Prado, Renata Belotto, João Paulo Tardivo, Mauricio S. Baptista, Waleska Kerllen Martins. “Photobiomodulation: Cellular, molecular, and clinical aspects” Journal of Photochemistry and Photobiology 2023(17): 00197 Ferraresi, C. et al. (2016) “Effects of Light-Emitting Diode Therapy on Muscle Hypertrophy, Gene Expression, Performance, Damage, and Delayed-Onset Muscle Soreness: Case-control Study with a Pair of Identical Twins” American Journal of Physical Medicine & Rehabilitation 2016;95(10): 746-757 Finlayson L, Barnard IRM, McMillan L, et al. “Depth penetration of light into skin as a function of wavelength from 200 to 1000 nm” Photochem Photobiol. 2021;98(4):396–408 Foley J, Vasily DB, Bradle J, Rudio C, Calderhead RG. “830 nm light-emitting diode (led) phototherapy significantly reduced return-to-play in injured university athletes: a pilot study” Laser Ther. 2016;25(1):35-42 Guimarães LS, Costa LDCM, Araujo AC, et al. “Photobiomodulation therapy is not better than placebo in patients with chronic nonspecific low back pain: a randomized, placebo‑controlled trial” Pain. 2021;162(6):1612–1620 Hamblin MR. “Mechanisms and applications of the anti-inflammatory effects of photobiomodulation” AIMS Biophys. 2017;4(3):337-361 Kons RL, Orssatto LBR, Detanico D, et al. “Effects of photobiomodulation therapy on fatigue and muscle damage markers in judo athletes” Front Physiol. 2019;10:811 Lawrence J, Sorra K. “Photobiomodulation as Medicine: Low-Level Laser Therapy (LLLT) for Acute Tissue Injury or Sport Performance Recovery” Journal of Functional Morphology and Kinesiology. 2024; 9(4):181 Martimbianco ALC, Ferreira RES, Latorraca C de OC, Bussadori SK, Pacheco RL, Riera R. “Photobiomodulation with low-level laser therapy for treating Achilles tendinopathy: a systematic review and meta-analysis” Clinical Rehabilitation. 2020;34(6):713-722 Morgan, Richard M.; Wheeler, Tyler D.; Poolman, Mark A.; Haugen, Erin N. J.; LeMire, Steven D.; Fitzgerald, John S. “Effects of Photobiomodulation on Pain and Return to Play of Injured Athletes: A Systematic Review and Meta-analysis” Journal of Strength and Conditioning Research 38(6):p e310-e319, June 2024 Naterstad IF, Joensen J, Bjordal JM, et al. “Efficacy of low‑level laser therapy in patients with lower extremity tendinopathy or plantar fasciitis: systematic review and meta‑analysis of randomized controlled trials” BMJ Open. 2022;12(9):e059479 Orssatto LBR, Detanico D, Kons RL, et al. “Photobiomodulation therapy does not attenuate fatigue and muscle damage in judo athletes: a randomized, triple‑blind, placebo‑controlled trial” Front Physiol. 2019;10:811 Tripodi, N., Feehan, J., Husaric, M. et al. “The effect of low-level red and near-infrared photobiomodulation on pain and function in tendinopathy: a systematic review and meta-analysis of randomized control trials” BMC Sports Sci Med Rehabil 13, 91 (2021) Tumilty S, Munn J, McDonough S, et al. “Low‑level laser treatment of tendinopathy: a systematic review with meta‑analysis” Photomed Laser Surg. 2010;28(1):3–16 Zein R, Selting W, Hamblin MR. “Review of light parameters and photobiomodulation efficacy: dive into complexity” J Biomed Opt. 2018;23(12):1-17

With proximal or high hamstring tendinopathy, prevention is definitely better than cure! In this article I’ll share five tips that may help you to avoid this injury. Some of the links in this article are to pages where you can buy products or brands discussed or mentioned here. We earn a small commission on the sale of these products at no extra cost to you. In this article: Quick recap on what causes high hamstring tendinopathy 5 Tips for avoiding high hamstring tendinopathy How we can help 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). Examples include: 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 wary 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 two 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. These memory foam / gel cushions are designed to take the pressure off your hamstring tendons when you sit: How we can help 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. For help with an Achilles injury, you can head over to our specialists at Treat My Achilles . We're all UK Chartered Physiotherapists with Master’s Degrees related to Sports & Exercise Medicine or at least 10 years' experience in the field. But at Sports Injury Physio we don't just value qualifications; all of us also have a wealth of experience working with athletes across a broad variety of sports, ranging from recreationally active people to professional athletes. You can meet the team here . About the Author Maryke Louw  is a chartered physiotherapist with more than 20 years' experience and a Master’s Degree in Sports Injury Management. Follow her on LinkedIn  and ResearchGate . References Brukner, P, et al. Brukner & Khan's Clinical Sports Medicine. Vol 1: Injuries. (2017) McGraw-Hill Education. (Links to Amazon) 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. Beatty, N. R., et al. (2017). "Rehabilitation and prevention of proximal hamstring tendinopathy." Current Sports Medicine Reports 16(3): 162-171. Goom, T. S., et al. (2016). "Proximal hamstring tendinopathy: clinical aspects of assessment and management." Journal of Orthopaedic & Sports Physical Therapy 46(6): 483-493.

Sitting, something we rarely think about, becomes difficult with high hamstring tendinopathy. The pain can feel relentless, but it’s important to know that this usually isn’t a sign of serious injury. Learn how to balance sitting – not too much, not too little – to reduce pain and support your recovery. Remember, if you need more help with an injury, you're welcome to consult one of our physios online via video call. This article contains affiliate links. We might earn a small commission on sales at no extra cost to you. In this article: Pain does not indicate how bad your injury is Finding the Goldilocks zone for sitting Tips to make sitting less painful How we can help We’ve also made a video about this: 👉 Read more about other aspects of high hamstring tendinopathy here . Recovering from a high hamstring tendinopathy has the added challenge that sitting is often painful, and the more you sit, the more painful it gets. Which means that many aspects of your life become complicated: working (if you’re doing a desk job), commuting and travelling, socialising, and just relaxing at home. Pain does not indicate how bad your injury is When you have a high hamstring tendinopathy, the pain can vary from just being a niggly pain – uncomfortable when you've sat for an hour or so – to an excruciating pain that means you can't sit for more than five to ten minutes before you have to get up. We used to think that the worse your pain is, the worse your injury is. But research , using MRI scans, has now shown that there’s not always a correlation between the amount of pain and how bad the tissue damage is. Some people can have a very bad injury and little pain, whereas others might have severe pain while the scan shows that the injury is not very serious or has indeed healed completely. 💡 This is important for how to approach high hamstring tendinopathy and sitting. I've previously explained in detail why pain levels can vary so much and often doesn't match the injury state. Finding the Goldilocks zone for sitting First, you should know that painful sitting is not going to make your tendon injury worse  as such. However, if you aggravate the pain, the pain becomes a bigger problem than the injury itself, because this is now what is ruling and ruining your life. ⚖️ Sitting too much is just as detrimental as avoiding it at all cost. Sitting too much 👎 If you try to ignore it and “sit through the pain”, your body’s alarm system will go into overdrive and create even more pain, which means your pain threshold becomes lower and you can sit for shorter and shorter periods of time with increasing pain. It’s like constantly prodding a bruise – you’re not going to make the  injury worse, but the sensitivity will increase if you keep on doing it. Learn how this works here. Sitting too little is just as unhelpful as sitting too much Sitting too little 👎 However, our alarm systems (which live in our subconscious minds) also respond to emotions like stress and fear and the stories we tell ourselves. So, if you’re fearful of sitting and start avoiding it while telling yourself it’s bad for you, your alarm system will also get dialled up, and even the slightest amount of sitting can trigger the pain. On a physical level, your injured tendon needs to get used to getting sat on again … but gradually. Also, standing for most of the day when you’re not used to it might affect other areas of your body negatively – back pain and foot injuries like plantar fasciitis might rear their heads. So, what to do? Sitting should be a part of your rehab 👍 The ultimate aim is to restore your sitting tolerance. With this in mind, we advise our patients to sit when they can sit, for as long as is comfortable. So, they don't force themselves to sit for longer and sit through pain, but they also don't avoid it fully. We also encourage them to test different surfaces and habits (see tips below) to find the ideal mix that allows them to sit for as long as possible in a day. And then we get them to slowly build it from there, just like with the rest of their rehab. This is a dynamic situation. If you get the Goldilocks zone right, you will find that you are able to sit for longer periods. This is because your tendon would have been getting better thanks to the rehab programme you’re following and because your pain system is getting back to normal and not constantly being irritated  because you’re sitting for too long. 💡 It's normal to find that, depending on what else you do in your day, your tolerance to sitting varies , e.g. you might find that your tendons want you to take more regular breaks after you've done a harder workout. The best approach is to listen to your body and adapt it accordingly. Tips to make sitting less painful 🪑 Surfaces Soft but firm is the way to go. A memory foam or gel cushion can be useful if your current sitting surfaces are too hard. It works for some people to move the cushion slightly forward  so that it supports their thighs but there’s no direct pressure on their sit-bones. These cushions are designed to reduce the pressure when you sit: 🧘 Positions The general guideline is that your hips should be higher than your knees. Sitting with your hips lower than your knees stretches the injured tendon over your sit bone, which might increase your pain. For example, avoid sitting in soft, deep, easy chairs or couches. When you drive or sit in a car, see whether you can lift your hips somewhat by using a memory foam cushion. Another position that will stretch your tendon over your sit bone is sitting upright in bed or with your feet on a footstool or Ottoman with your legs straight out in front of you. Going out with friends? Perching on a high stool can often be most comfortable – you can also try just having one buttock on it at a time. Sitting with your hips lower than your knees increases the angle at your hips, which causes a mild stretch on the upper hamstring tendons. 🕜 Take regular breaks from sitting If you have to sit a lot during the day (e.g. you’re chained to your desk) it’s a good idea to get up every so often even before the pain kicks in.   By getting up before the pain system is significantly triggered , you can often avoid it getting super painful. This can  increase your “total sitting time” for the day. Try doing some light exercise during your breaks (maybe your rehab exercises or even just a short walk) – this will increase the circulation to your injured tendon and can help to “reset” your alarm system. How much pain before you get up? This is not an exact science, but you want to get up before it feels like a significant increase above your normal non-sitting pain levels. 👉 The ultimate aim is that, by the end of the day, your tendon is only a bit more uncomfortable than normal and this “extra” discomfort should ideally settle back down to your normal levels by the next morning. Here’s our article with more detail on how to take regular breaks from sitting . ✍️ Keep a sitting diary Keeping a “sitting diary” can be useful to establish the right amount of sitting and make you aware of what you can actually do. I've often have patients say "I can't sit", only to come back in the next follow-up appointment and report, that actually, they can sit for x amount of time. They weren't trying to exaggerate before — they've just been experiencing pain so often that their subconscious had created a (not very accurate) story that they started to believe about sitting. A sitting diary forces you to pay attention to the actual reality and helps to restore perspective. The diary is not just for logging how long you’re sitting, you can also add what surfaces you’re sitting on and in what positions before you have to get up due to increased pain. It’s also a great tool to help you see progress over time. High hamstring pain can take a very long time to recover and you will have days when it feels like you’ve not made any progress. When this happens, it can be useful to look at your diary and see how far you’ve come. How we can help 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. We're all UK Chartered Physiotherapists with Master’s Degrees related to Sports & Exercise Medicine or at least 10 years' experience in the field. But at Sports Injury Physio we don't just value qualifications; all of us also have a wealth of experience working with athletes across a broad variety of sports, ranging from recreationally active people to professional athletes. You can meet the team here . About the Author Maryke Louw is a chartered physiotherapist with more than 20 years' experience and a Master’s Degree in Sports Injury Management. Follow her on LinkedIn and ResearchGate . References Butler, D. and Mosely, L. (2013) “Explain Pain” Noigroup Publications: Adelaide, Australia. Hanlon, S.L. et al. (2021) “Beyond the Diagnosis: Using Patient Characteristics and Domains of Tendon Health to Identify Latent Subgroups of Achilles Tendinopathy” J Orthop Sports Phys Ther 51(9): 440-448.

Patellar tendonitis treatment can involve various options. In this article, we explain why we recommend the approach of relative rest and a graded strength training programme for treating patellar tendonitis to most of our patients. We also discuss what other treatment options could be used in addition to this, as well as the causes and symptoms of patellar tendonitis. Remember, if you need more help with an injury, you're welcome to consult one of our physios online via video call. Some of the links in this article are to pages where you can buy products discussed or mentioned here. We might earn a small commission on the sale of these at no extra cost to you. In this article: What’s the difference between patellar tendonitis and tendinopathy? What is patellar tendonitis? What causes patellar tendonitis? What happens to the tendon when you have patellar tendonitis? Patellar tendonitis symptoms - what does it feel like? Patellar tendonitis recovery time Patellar tendonitis treatment How we can help I've also made a video about the causes and treatment of patellar tendonitis/tendinopathy: What’s the difference between patellar tendonitis and tendinopathy? For all practical purposes, it means the same thing. But in 2019, a bunch of the world leading experts on tendons decided that the best terminology for this sort of problem would be tendinopathy, rather than than tendonitis. This is because '-itis' in the 'tendonitis' refers to inflammation, and researchers no longer think that inflammation is a key feature of this problem. In this article, we use the terms interchangeably. What is patellar tendonitis? Patellar tendonitis is an overuse injury that affects the patellar tendon. The patellar tendon is a thick tendon that runs over the front of your knee, from the lower edge of your kneecap (patella) to the front of the shin bone (tibia). It attaches your quadriceps muscles (front thigh muscles) to the shin bone. Any activity that activates or uses the quadriceps muscles also loads the patellar tendon. Patellar tendonitis is most commonly found in people who do sports and activities that require a lot of fast, repetitive, high-force contractions of the quadriceps muscles, e.g. football/soccer, volleyball, tennis, long jump, fell running, and CrossFit. What causes patellar tendonitis? Overuse Overuse injuries like patellar tendonitis develop when you either: Do an activity that is a lot more intense or harder than what you’re used to, e.g. playing in a tournament that results in six hours of high-intensity play when you’re used to two hours; Or you don’t allow your body enough recovery time between high-intensity training sessions. Whenever we train, our bodies (tendons included) sustain microdamage. If you allow enough recovery time, your body repairs this microdamage and as a result you grow stronger. But if you do another high intensity session before your body has fully repaired, the microdamage can accumulate and cause an overuse injury. Trauma The vast majority of cases of patellar tendonitis are caused by overuse, but sometimes a direct blow to the patellar tendon (e.g. someone kicks you or you bang your knee against something) can also cause the tendon to develop patellar tendonitis or tendinopathy. What happens to the tendon when you have patellar tendonitis? Healthy tendons are extremely strong structures. They are made up of mostly lots and lots of collagen fibres that are packed in parallel. They also have a few cells and some (not a lot) white, fluid-like substance between the fibres. The collagen fibres in healthy tendons are packed close together, in parallel. It’s the parallel structure of the collagen fibres that makes a tendon so strong. Remember that old experiment from school with the pieces of string? If you take one piece of string, it’s easy to snap. But as soon as you have ten pieces of string put together, it becomes impossible to snap them with your bare hands. When you develop a tendonitis or tendinopathy, it only affects a small portion of the tendon. For the patellar tendon, it most often affects the area where the tendon attaches to the lower edge of the kneecap. When you look at that injured part under a microscope, you’ll notice: In newly injured tendons - That the collagen fibres have started to move away from each other, there’s more of the fluid-like substance between them, and the cells have also changed. Microscopic image of a recently injured tendon (reactive tendonitis). If your patellar tendonitis has been dragging on for a month or two, you may notice that the collagen fibres in that area have totally lost their parallel structure, and there’s much more fluid-like substance. An ultrasound scan may also show new blood vessels growing into that area. Healthy tendons usually don’t have blood vessels growing into them. Microscopic image of an ongoing tendonitis/tendinopathy. The injured potion of the tendon has lost its parallel structure. Patellar tendonitis symptoms - what does it feel like? Where you feel patellar tendonitis pain The pain is felt over the front of the knee and most often in the area where the patellar tendon attaches to the lower edge of the kneecap. But it is possible to get it in other parts of the tendon. Most commonly the pain from patellar tendonitis is felt at the lower edge of the kneecap. Other conditions that can cause similar pain and are often mistaken for patellar tendonitis include quadriceps tendinopathy, infrapatellar bursitis, fat pad irritation, patellofemoral pain syndrome , meniscus tears , Osgood Schlatter’s (in children) and Sinding-Larsen-Johansson syndrome (in children). When does it hurt? It hurts whenever you do an activity that uses the quadriceps muscles (front thigh muscles). If your tendon is very irritated, even light activities like walking up and down stairs may hurt. If it’s not that irritated, then you may only feel pain when you do high-intensity activities like heavy squats, jumping, or running. You may find that your knee actually feels pretty good when you start with your activity, but then the pain slowly starts to build as you continue. Or you may have some pain when you start training, but then it actually goes away as you warm up, only to return much more intensely later on. If you’ve neglected your patellar tendonitis for a while and continued to train through the pain, you may find that it’s too painful to do sport. It is quite common to experience a delayed increase in pain, i.e. it is only 24 hours after doing an activity or training session that you suddenly experience an increase in pain. This is what makes tendon rehab so tricky - it usually doesn’t let you know at the moment when you’re overdoing things. That is why we teach our patients to monitor and interpret their 24-hour pain response rather than just focus on what they experience while they're doing their sport or activity. Patellar tendonitis can sometimes cause pain when you sit with your knee bent for a long period. This is because the injured patellar tendon is under a bit of stretch and compression when your knee is bent, and that can cause it to become irritated if the position is sustained for too long. However, this is also a common occurrence when you have patellofemoral pain syndrome and why it’s best to consult a physio who can help you figure out your correct diagnosis. Patellar tendonitis recovery time Patellar tendonitis, like all tendon injuries, can take a very long time to heal. Most people will recover and return to full sport within six months. But researchers have found that up to a third of athletes will take longer than six months to recover and often more than a year. This is why it’s important to seek help early on to ensure that you’re applying the most appropriate treatment plan for your specific case. Patellar tendonitis treatment The successful treatment of patellar tendonitis usually involves a combination of different activities and treatment modalities. We've included the most widely used and best researched ones in the sections below. 1. Relative rest Relative rest is different from complete rest in that you don’t have to stop all your activities. You can remain active as long as you reduce your activity intensity and volume to a level that doesn’t increase your pain. The aim is to allow your tendon to settle down, so that you can progress with your rehab and build the strength you need to go back to full sport. By how much you have to adapt your training will depend on how irritated your tendon is. For some athletes, this may mean that they have to stop all jumping and sprinting and just do low-load activities like walking or slow jogging. For others, it may mean that they just have to limit the volume, intensity, or frequency of their jumping and sprinting activities. We always aim to keep our patients as active as possible, as that helps to maintain their current tendon strength. But this is not an exact science and requires careful monitoring to get it right. Remember that relative rest should also take account of your normal day-to-day activities, and there are some everyday movements and positions that may aggravate your patellar tendon pain . Current recommendation You have to reduce the intensity of your activities to allow your tendon to calm down. Relative rest is superior to complete rest, as it not only allows the pain to settle but also retains more strength in the tendon. 2. Rehab for patellar tendonitis Strength training exercises There is very strong evidence that the best treatment for patellar tendonitis or tendinopathy is a structured strength training plan, consisting of exercises that specifically load the patellar tendon . This should not come as a surprise because, as we discussed earlier, when you injure your tendon it changes structure and loses some of its strength. The only way to trigger the body to produce new tendon fibres and restore its strength to the level you need is strength training exercises. What exercises you should do for patellar tendonitis is determined by your stage of healing, the sensitivity of your tendon, your sport, and your current strength. Recent research has shown that there’s a wide variety of strength exercises and programmes that could work for treating patellar tendonitis - we discuss them in detail in this article . In our experience, not everyone reacts equally well to the same exercises. Every case of patellar tendonitis differs in severity and irritability and people also have different end goals. So it’s important that the exercise programme is tailored to the individual and adapted as your tendon heals. Kinetic chain When we move, our bodies function as a kinetic chain which means that if something happens in one area, it also affects areas that are further away. A lack of flexibility or strength in one area may for instance cause another area to overwork or overstrain. Some areas in the kinetic chain that may affect your patellar tendon. There is evidence that lack of hamstring and quadriceps flexibility, restricted ankle dorsiflexion range (how well your foot bends up towards your shin), as well as reduced calf and glute function may increase your risk of developing patellar tendonitis. This is why we do a comprehensive assessment of our patients and don’t just focus on their painful knees. Biomechanics Biomechanics refers to the movement patterns we use when we do different activities. For patellar tendonitis, the landing mechanics from a jump has been shown to be of importance. Box jumps help to develop explosive strength and teach good landing mechanics. This is perhaps not something that needs to be addressed during the early stages of rehabilitation, as your biomechanics may be different when you are still in pain and these exercises can easily irritate the tendon. But it is definitely something that should be assessed during the later stages, once you’ve built some strength and your pain has settled. We’ll discuss the different exercise programmes and what an ideal exercise-based treatment plan for patellar tendinopathy should look like in a future blog post. Current recommendation Exercise remains the most effective treatment for patellar tendonitis, and several literature reviews have now confirmed this, but the exercise programme should be tailored to the individual needs of the patient and be adapted as their injury recovers. A one-size-fits-all approach is likely to aggravate the symptoms. 3. Ice Intermittent icing might help to reduce your pain because it numbs the nerve endings. This won't speed up the healing process as such, but it might make it easier for you to stick to your strength training exercises (see above) if they cause you pain. Current recommendation If your rehab exercises are painful, try applying ice before you do them. Aim for three applications of 10 minutes each, with 10-minute breaks inbetween. Don't ice your tendon directly after you've done your exercises; research has shown that you gain less from strength training if you regularly cool the tissue afterwards. You can read more about how to use ice for injuries in this article . 4. Shockwave Shockwave can be a useful tool to help reduce pain. However, a recent meta-analysis of the current research found that adding shockwave to an exercise-based treatment programme for patellar tendonitis added no extra benefit. Current recommendation If pain is preventing you from doing any exercises or from making progress with your rehab, it may be useful to try shockwave, as it may reduce your pain sufficiently to allow you to progress with your rehab. However, if you’re already able to tolerate your rehab exercises, you're not likely to gain any extra benefit from adding shockwave to your treatment regime. 5. Massage Massage may be useful to help reduce pain in the short term, but it doesn’t actually strengthen the tendon. Exercise has been shown to provide better short and long term results for pain reduction than cross-friction massage specifically. Current recommendation Don’t rely on massage alone for your recovery. You have to also follow a structured exercise-based rehab programme. 6. Anti-inflammatory medication Anti-inflammatory medications (NSAIDs) like ibuprofen or Naproxen are sometimes prescribed to help decrease your pain when you have patellar tendonitis. However, the research has shown that inflammation isn’t actually what causes the pain in ongoing tendonitis or tendinopathy. More importantly, research has also shown that anti-inflammatory medication may slow down the rate at which your body creates new collagen fibres in response to exercise. The whole point of doing the strength training exercises is to stimulate your body to produce new collagen fibres and to strengthen your injured tendon! Current recommendation Don’t use anti-inflammatory medication to treat patellar tendonitis. Discuss other options for pain management with your doctor. Paracetamol might be a better choice. Anti-inflammatory medication may reduce the benefits your patellar tendon is meant to gain from doing rehab exercises. 7. Topical glyceryl trinitrate There is some evidence that using topical (applied to the skin) glyceryl trinitrate in combination with an exercise plan may work better for reducing pain than exercise on it’s own. However, it does come with some side effects that may include skin irritation and headaches. Current recommendation Topical glyceryl trinitrate may be an useful adjunct to treatment if you’ve not seen any progress with your exercise programme after 12 weeks. 8. Platelet rich plasma (PRP) injections There is some evidence that PRP injections may be useful as part of the treatment for patellar tendonitis, but only when it is combined with an exercise plan. We are not yet sure what technique is superior or how many injections work best. They also don’t work for everyone. Current recommendation PRP injections on their own are not useful. They have to be combined with a graded strength training plan. It’s a treatment to consider if you’ve failed to make significant progress after 12 weeks of following a tailored exercise programme. PRP injections may be useful for treating patellar tendonitis, but corticosteroid injections should be avoided. 9. Steroid injections In the past, a steroid (corticosteroid or cortisone) injection was a standard treatment for any tendon injury, because it is pretty good at reducing the pain. However, now that a lot more research has been done, it has become clear that it might not be a good idea to inject a tendon with cortisone. Cortisone has been shown to slow healing and may predispose you to a tendon rupture. Steph discusses the use of steroid injections in more detail in this video. Current recommendation Do not use cortisone or steroid injections to treat patellar tendonitis/tendinopathy. 10. Patellar tendonitis strap or taping Some people find that using a patellar strap that applies pressure over the patellar tendon can reduce their pain while playing sport. Others find that tape can also provide some relief. There currently isn't much high-quality research available to back this up. A recent randomized controlled trial did show that both patellar tendon straps and tape can help to reduce pain, but they failed to show a significant difference between using a patellar tendon strap, applying a specific taping technique, and placebo tape (tape just stuck on in any way). Current recommendation A patellar strap may reduce your pain while playing sport, but this would likely be due to a placebo effect. Don't use this as a standalone treatment for patellar tendonitis. Make sure that you combine it with a comprehensive rehab plan. 11. Surgery Surgery should only be considered if you’ve followed a structured and progressive strength training programme for at least 12 months and not seen any progress. About 10% of patients with patellar tendinopathy seem to undergo surgery. There is currently no consensus on what type of surgery is best. Current recommendation Only consider surgery if you’ve failed to get results from a well-designed (tailored to you) exercise-based treatment plan for at least 12 months. How we can help 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. We're all UK Chartered Physiotherapists with Master’s Degrees related to Sports & Exercise Medicine. But at Sports Injury Physio we don't just value qualifications; all of us also have a wealth of experience working with athletes across a broad variety of sports, ranging from recreationally active people to professional athletes. You can meet the team here . About the Author Maryke Louw is a chartered physiotherapist with more than 15 years' experience and a Master’s Degree in Sports Injury Management. Follow her on LinkedIn and ResearchGate . References Burton, I. (2022). "Interventions for prevention and in-season management of patellar tendinopathy in athletes: A scoping review." Physical Therapy in Sport. Challoumas, D., et al. (2021). "Management of patellar tendinopathy: a systematic review and network meta-analysis of randomised studies." BMJ Open Sport & Exercise Medicine 7(4): e001110. Christensen, B., et al. (2011). "Effect of anti-inflammatory medication on the running-induced rise in patella tendon collagen synthesis in humans." Journal of Applied Physiology 110(1): 137-141. Cook, J. L., et al. (2016). "Revisiting the continuum model of tendon pathology: what is its merit in clinical practice and research?" British Journal of Sports Medicine 50(19): 1187-1191. de Vries, A., et al. (2016). "Effect of patellar strap and sports tape on pain in patellar tendinopathy: a randomized controlled trial." Scandinavian Journal of Medicine & Science in Sports 26(10): 1217-1224. Longo, U. G., et al. (2018). "Achilles Tendinopathy." Sports Medicine and Arthroscopy Review 26(1): 16-30. Magra, M. and N. Maffulli (2006). Nonsteroidal antiinflammatory drugs in tendinopathy: friend or foe, LWW. Malliaras, P., et al. (2015). "Patellar tendinopathy: clinical diagnosis, load management, and advice for challenging case presentations." Journal of Orthopaedic & Sports Physical Therapy 45(11): 887-898. Virchenko O, Skoglund B, Aspenberg P. Parecoxib impairs early tendon repair but improves later remodeling. Am J Sports Med. 2004;32:1–5.

Learn what causes proximal hamstring tendinopathy, how to recognise its symptoms and what stage your injury is in, as well as the tests used for diagnosis. Remember, if you need help with an injury, you're welcome to consult one of our physios online via video call. In this article: What causes proximal hamstring tendinopathy? The stages of proximal hamstring tendinopathy (and why this matters) Pain is not an indicator of how bad your injury is How to know whether you have proximal hamstring tendinopathy How we can help We've also made a video about it: 👉 Read more about other aspects of high hamstring tendinopathy here . What causes proximal hamstring tendinopathy? Proximal hamstring tendinopathy (aka high hamstring tendinopathy) develops in the tendons that attach the top end of your hamstring muscles to your sit bone (ischial tuberosity). You also have hamstring tendons lower down in your leg that can get injured, but that’s known as distal (or lower) hamstring tendinopathy . The hamstring muscles work together to pull your leg back (extend your hip) and bend your knee as you walk, run, and jump. They also help to control movements like bending forward (similar to doing a deadlift). The natural cycle of tissue breakdown and repair Tendons are made up mostly of collagen fibres, packed tightly in parallel. It is this parallel structure that makes them so strong. What healthy tendon tissue looks like under a microscope. When we exercise or do activities that use our muscles and tendons, they naturally get micro-injuries. These injuries are normal – they signal to the brain that the tissue needs to be made stronger. 👍  If you allow enough recovery time between bouts of work or exercise, your body then repairs these small injuries so that the various affected tissues grow stronger over time. This is why someone who has been doing a physical job or specific exercise for a long time can do so much more than someone who is just starting out. Where things go wrong If you repeatedly don’t allow enough recovery time between hard bouts of work or exercise, or you ramp up the intensity or volume too quickly , your body doesn’t have enough time to repair these micro-injuries properly. They then accumulate over time and can cause overuse injuries like proximal hamstring tendinopathy. Furthermore, specifically for the hamstring tendons: Any activity or action that overworks the hamstring muscles will also cause excessive force on the tendons and their attachments and can cause a tendinopathy. With proximal hamstring tendinopathy there is also the possibility of excessive compression of the tendon against the sit bone, which is thought to play a major role in developing this injury. The upper hamstring tendons naturally pull tight and press against the sit bone as you bend your hip forward or up (when you sit, take a step, squat down, or do a hamstring stretch). Normally, this is not a problem, but if it happens more often or more forcefully than the tendon is used to, it can cause trouble. Common factors leading to high hamstring tendinopathy 1️⃣ Training errors: Increasing your training volume or intensity too quickly, or not allowing enough recovery time after training sessions are some of the most common training errors that lead to tendinopathies. And if these activities work the hamstrings hard in positions where the tendons compress strongly against the sit bone, they are more likely to overwork the high hamstring tendons. Examples include: Uphill walking or running Running in general – the faster or further you run, the more it affects it Cycling – especially if using low-drop handlebars (so your hips are more flexed) and high resistance Squats, lunges, and deadlifts – not just in the gym but also as part of daily life, e.g. bending over to do a lot of weeding in the garden when you’re not used to it. Overstretching is a common cause of proximal hamstring tendinopathy. 2️⃣ Overstretching:  Activities like yoga and Pilates that involve deep, prolonged hip flexion stretches (e.g. forward folds) can put too much strain on the tendon. 3️⃣ Sitting too much: When we sit, we place most of our weight on our sit-bones. Your specific genetics (shape of your skeleton) as well as the shape of the chair (e.g. low vs. high seats) and how hard the surface is will determine how much pressure is placed on the upper hamstring tendons. If you sit for very long periods without taking breaks, it might create enough compression to trigger proximal tendinopathy. 👉  None of these activities has to be a problem – it is only when you do them excessively or you suddenly ramp up how much you do them that the injury might develop. Other contributing factors There are other factors that might make you more prone to developing proximal hamstring tendinopathy. Genetics:  There are certain genes (e.g. the ones linked to hypermobility syndromes like Ehlers-Danlos syndrome) that can affect the quality of your collagen (the main building block of tendons) and how easily your body produces it, which might increase your risk of tendon injuries. General health:  High cholesterol, diabetes, and thyroid problems can make tendons more vulnerable to injury. The menopause:  Women in any stage of the menopause might be at higher risk , because declining oestrogen levels can slow down collagen production. Medication: Some antibiotics, particularly fluoroquinolones , have been linked to tendon problems. Statins , often prescribed for high cholesterol, can also cause tendon pain in some people. Some types of medication might contribute to tendon pain. The stages of proximal hamstring tendinopathy (and why this matters) When our patients come to us for proximal hamstring tendinopathy treatment, their hamstring tendons will be in a specific stage of healing or injury, depending on how long they’ve had it for. This matters, because the best treatments for the various stages differ quite a bit. 👉 It’s worth noting that the stage of your injury is not the only factor influencing the choice of treatment. How sensitive your tendon is and its current level of strength also play a role. You can read more about this in our other article on treatments (coming soon). The three stages of proximal hamstring tendinopathy (and other overuse tendon injuries) are: 1. Reactive tendinopathy This is typically the stage in which your tendon is when you first injure it, i.e. your tendon pain and stiffness started a few days or weeks ago. There's usually no permanent structural damage in new or recent tendinopathy cases. 🔬 What scans show:  When you scan the tendon, it typically shows an accumulation of fluid between the collagen fibres, but without major structural changes or injuries to these fibres. There might be a few inflammatory cells, but researchers seem to agree that inflammation is not the main cause of the pain. 🏃‍♀️‍➡️ Impact on recovery:  The good news is, if you apply the correct treatment during the reactive stage, the tendon can fully recover without suffering permanent structural changes. 👍  The best ways to deal  with proximal hamstring tendinopathy during this stage are rest, load management, and treatments that will help it to settled down. 👎  The worst things you can do  during this stage are strength training exercises and stretches. (I’ll explain why in the treatment article to be published shortly.) 2. Tendon dysrepair If the newly injured tendon isn’t allowed to rest and calm down and you continue to irritate it while it’s in the reactive stage (either through too much physical activity or perhaps by applying the wrong treatments), it might enter the dysrepair stage. Instead of healing, the injury gets a bit worse. 🔬 What scans show:  During the dysrepair stage, in addition to extra fluid in the tendon, you start seeing the collagen fibres moving away from each other and starting to lose their nice, strong, parallel structure. It’s worth noting that this tends to affect only a small portion of the tendon – the rest of the tendon is still strong and healthy.  There are usually also small blood vessels growing into the tendon, which are normally absent, and there are no signs of inflammation. 🏃‍♀️‍➡️ Impact on recovery:  Recovery tends to take a bit longer than in the reactive stage. There is evidence that the tendon structure can revert to normal with the correct mix of load management and careful loading. (Keep an eye out for our treatment article – I’ll discuss it there.) 3. Degenerative tendinopathy This stage sounds a lot more serious than what it actually is. In general I try to avoid using the word "degenerative" because it makes people think of permanent damage and something that won't heal, which is NOT THE CASE. You can still get back to full, pain-free activity even if you think you've entered this stage. The injured part of your tendon might have entered this stage if the injury has been allowed to drag on for several months. The collagen fibres in the injured part of the tendon lose their parallel structure and becomes deconditioned. 🔬 What scans show:  The injured area of the tendon (remember, this is usually only a small part ) now shows signs that the collagen fibres have been damaged and have totally lost their parallel structure. You also see many blood vessels growing into the area. There is no inflammation. 🏃‍♀️‍➡️ Impact on recovery:  It usually takes even longer to get back to your full level of activity (9 to 18 months even) if you're in this stage. The injured area will likely not “look” normal again on scans (similar to how a scar looks on your knee), but this really doesn't matter. Collagen is super strong tissue ( research has shown it to be 10 times stronger than steel) and tendons, just like muscles, can get bigger and stronger through exercise. Recovery in this stage of injury depends on getting the rest of the tendon (the uninjured part) to grow stronger to take over the work of the injured part. 👍 The best treatments for proximal hamstring tendinopathy during this period should focus on reducing pain and increasing the tendon’s strength with a training plan that gradually becomes more challenging. Often, this involves specific strength training exercises, but in some cases activities like walking, climbing, or very gradually easing into running work better – every person is different. Pain is not an indicator of how bad your injury is People with proximal hamstring tendinopathy can experience very different levels of pain. For some, it might just be a mild discomfort that only shows up during activities that place a high load on the tendon – like long-distance running. Others might feel quite a bit of pain even when the tendon isn’t being used much. It’s helpful to know that imaging studies  have shown that pain levels don’t necessarily reflect how badly the tendon is injured. Scans might show only a small issue, yet the pain can be quite severe – or the other way around. Studies have also found that pain can feel worse if: the injury has been around for more than three months, if you’re dealing with a lot of stress, not sleeping well, or if you feel pessimistic about your chances of recovery. So, while it’s essential to treat the tendinopathy, it’s also worth tackling these other things if your pain feels particularly intense or just won’t go away. If you'd like to explore this idea further, I've written a detailed article about all the factors that might be making your pain feel worse than it should. How to know whether you have proximal hamstring tendinopathy Your doctor or physiotherapist will usually make the diagnosis by combining information  from the in-depth conversation you have about your injury (how it started, what the symptoms feel like, and how they react) with specific movements tests and, in some cases, scans. This is also how we diagnose it via video call. Let’s break this down in more detail. Proximal hamstring tendinopathy symptoms Your physio or doctor will likely ask about the following: What the symptoms feel like:  The main symptoms of proximal hamstring tendinopathy are pain and stiffness. 💡If you’re getting tingling, weird sensations or numbness, it might mean that you’ve injured or irritated a nerve; this can be in addition to or instead of proximal hamstring tendinopathy. Your physio can easily test for this (even via video call) by performing the slump test . Location of the symptoms:  The pain is mainly in the area of the sit-bone or just below it. In ongoing cases, you may get some stiffness and pain going into your lower thigh or buttock. 💡If you’re getting back pain, strong glute pain, or the main pain is actually more to the outer edge of the thigh (more lateral), it might be worth getting it checked, as you may have a different injury. Where you feel the pain, how it started, and how it reacts to various activities are important factors for making the diagnosis. How the symptoms started:  Proximal hamstring tendinopathy symptoms usually start gradually during an activity, several hours after the activity, or you may even wake up with the pain and stiffness the day after an activity. 💡If your symptoms started when you felt a sudden, sharp pain while doing something, it might be a tear rather than a tendinopathy. How the symptoms react to activities: The pain tends to get worse during or after movements that load the hamstring while your hip is bent forward – like squats, lunges, deadlifts, or even uphill walking or running. Sitting is another common trigger and can make the pain flare up. After long periods of being inactive – like sitting for a while or first thing in the morning after a night’s rest – the tendon often feels stiffer and sorer. Once you start moving, it usually loosens up as it warms up, although sometimes the discomfort can stick around throughout the day. You might notice symptoms most at the beginning of a run or workout. As you continue, the pain may settle, only to return later – sometimes more strongly – a few hours after you’ve finished. Stretches that involve deep hip flexion, like hamstring, glute, or piriformis stretches, can also aggravate the tendon. 💡If your pain is also worse when you do low-load activities with the hip in a straighter position, e.g. while sleeping or walking slowly on flat surfaces, it might be coming from a different area, e.g. your lower back. Stretching your hamstrings may feel good in the moment but often causes a delayed increase in pain. Tests for proximal hamstring tendinopathy People often expect physios or doctors to figure out what’s wrong just by pressing on the sore spot. But for high hamstring tendinopathy, that’s not actually a very useful test.  Because of the way the sit bones are shaped and how the tendons attach, you can’t always reach the injured part by pressing on it. So, if pressing doesn’t bring on any pain, it doesn’t mean the tendon isn’t injured. A better approach is to use movement tests  that stretch or contract the hamstrings in different positions – especially if those movements also press the tendon against the sit bone. Every tendon injury is a bit different, so the exact tests your physio uses will depend on what they’ve learned from talking to you about your symptoms. Usually, they’ll start with movements that don’t put too much load on the hamstrings and avoid positions that cause a lot of compression. Then they’ll gradually make the movements more challenging until they reach one that causes some discomfort – which would be seen as a positive test  (i.e. confirm you likely have proximal hamstring tendinopathy). 👉 Tendons can be a bit tricky – they don’t always let you know right away if they’re unhappy with a movement. That’s why it’s pretty common to have a pain flare-up the day after your assessment.  If that happens, let your physio know – it might mean your rehab plan needs tweaking. Bridge progression testing The bridge is a really versatile movement and can be adapted for almost anyone with high hamstring tendinopathy. You can make the hamstring muscles work harder by moving your feet further away from your bum, or by going from using both legs to just one. You can also increase the amount of compression on the tendon by bending the hip more – for example, moving from a bridge with your feet on the floor (hip not very flexed) to a bridge with your heels on a chair (starting at almost 90 degrees hip flexion, which creates much more compression in the early part of the movement). The fundamental bridge movement pattern (that can be adapted for the other versions) is as follows: Lie on your back with your knees bent 90 degrees and feet flat on the floor. Tighten your tummy muscles. Squeeze with your glutes (not your back muscles) to lift up your hips – just to where they naturally stop. You can then hold the position there for several seconds or come back down immediately. A typical bridge progression I might test could look like this: Double-leg bridge with feet on the floor and heels close to the bum Double-leg bridge with feet further out so the knees are at about 45 degrees If that’s fine, move to a single-leg bridge on the floor If that’s fine, try a double-leg bridge with feet supported on a chair Single-leg bridge with heel on a chair Single-leg high bridge with the knee more extended, or even with added weight over the pelvis. 👉  You obviously wouldn’t keep testing if any of these movements cause pain. And if a patient tells me their tendon flares up easily, I might stick to only the basic movements and stop before we reach the point of pain, so we can check for a delayed pain response. But if a patient says they can do a fair amount of sport with only mild discomfort, I know I can usually push them further in testing without risking a big flare-up. Romanian deadlift progression testing The Romanian deadlift (where you keep your knees slightly bent while hinging at the hips) is a really useful test for diagnosing high hamstring tendinopathy. It makes the hamstring tendons work while the hip is flexed, which increases compression between the tendons and the sit bone – something that’s more likely to irritate them if they’re injured. I choose which type of deadlift to test based on what my patient has told me about their symptoms. Here’s how to do the simplest version: Stand with your feet hip-width apart and bend your knees slightly. Engage your stomach muscles and keep your back straight. Begin bending forward from the hips, maintaining a straight back – it can help to guide the movement by sliding your hands down the front of your thighs. Stop when you feel pain, or when you reach the point where the only way to go lower would be to bend your back. This is your natural limit, and how far you can go will depend on how flexible your hamstrings are. If that doesn’t cause discomfort, you can make it progressively harder by adding weight or doing it on one leg. Here’s how I would rank the variations from lowest to highest compression/force: Double-leg deadlift, sliding hands down the thighs to the knees Double-leg deadlift while holding extra weight Single-leg deadlift Single-leg deadlift with extra weight. Bent-knee stretch test Another test that can help diagnose high hamstring tendinopathy is the bent-knee stretch test. In this test, you first bend the hip and then straighten the knee – this creates maximum compression between the sit bone and the tendons , and it tends to be better at picking up high hamstring tendon injuries than the version where you simply lift a straight leg. Your knee might not straighten this far if your hamstrings are tight. Here’s how to do it yourself: Lie on your back with your legs straight. Bend the leg you want to test so your knee comes as close to your stomach as possible, and hook a belt around your foot. Ideally, your hip should be bent to 90 degrees or more – but don’t force it. Using the belt for support, straighten your knee as far as it will comfortably go (it will likely not go completely straight) without forcing it. Don’t let your hip straighten – keep it bent to at least 90 degrees. If this test causes pain around your sit-bone area it might mean that you have high hamstring tendinopathy. 👉 No single movement test is 100% accurate, so your physio will usually have you do several and then combine the results to make a diagnosis. But if your injury is very easy to irritate, they may only perform one or two. What about scans? The best scans for diagnosing high hamstring tendinopathy are ultrasound and MRI scans. That said, you usually don’t need a scan to confirm the diagnosis. They’re generally only needed if your injury isn’t healing as expected, or if your doctor or physio suspects you might have a different type of injury – for example, a tendon tear or a nerve problem. It’s also important not to assume that your pain is definitely from tendinopathy just because the tendons show some changes on a scan. Studies have shown that many people with no symptoms at all still have “positive” scan results. So your doctor might still consider other possible causes for your pain – like nerve irritation – even if the scan shows changes in the tendon. How we can help Need 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. We're all UK Chartered Physiotherapists with Master’s Degrees related to Sports & Exercise Medicine or at least 10 years' experience in the field. But at Sports Injury Physio we don't just value qualifications; all of us also have a wealth of experience working with athletes across a broad variety of sports, ranging from recreationally active people to professional athletes. You can meet the team here . About the Author Maryke Louw is a chartered physiotherapist with more than 20 years' experience and a Master’s Degree in Sports Injury Management. Follow her on LinkedIn and ResearchGate . References Goom, T. S., Malliaras, P., Reiman, M. P., & Purdam, C. R. (2016). “Proximal hamstring tendinopathy: clinical aspects of assessment and management” Journal of Orthopaedic & Sports Physical Therapy, 46(6), 483-493. Lempainen, Lasse, Kristian Johansson, Ingo J. Banke, Juha Ranne, Keijo Mäkelä, Janne Sarimo, Pekka Niemi, and Sakari Orava. "Expert opinion: diagnosis and treatment of proximal hamstring tendinopathy" Muscles, Ligaments and Tendons Journal 5, no. 1 (2015): 23. Nasser, Anthony M., Tania Pizzari, Alison Grimaldi, Bill Vicenzino, Ebonie Rio, and Adam Ivan Semciw. "Proximal hamstring tendinopathy; expert physiotherapists’ perspectives on diagnosis, management and prevention" Physical Therapy in Sport 48 (2021): 67-75.

If you have proximal hamstring tendinopathy, certain stretches can actually make things worse instead of helping. In this article, we’ll look at the stretches to avoid and what you can do instead to ease the tightness and help your hamstring tendon to recover. Remember, if you need help with an injury, you're welcome to consult one of our physios online via video call. In this article: Why avoid certain stretches? Examples of stretches to avoid with proximal hamstring tendinopathy What to do instead How we can help Maryke has also done a video about this: Why avoid certain stretches? 👉 Any stretch that pulls the high hamstring tendons firmly over the sit bones  should usually be avoided if you have proximal hamstring tendinopathy. Why avoid these stretches? You know how it hurts when you prod a bruise? When the high hamstring tendons are injured, they also become very sensitive to compression . So if you do stretches that pull and press the tendons firmly against the sit bones, it usually just irritates them further and makes the pain worse. 💡 People with tendinopathies often have a natural urge to stretch the affected area, and these stretches can feel nice while you’re doing them, but a few hours later the pain often flares up. Examples of stretches to avoid with proximal hamstring tendinopathy ⭐ None of these stretches are "bad" for an uninjured hamstring – you can usually ease back into doing them once your tendons have calmed down and recovered their ability to tolerate these compression forces. 1️⃣ Hamstring stretches Any stretch where you keep your legs straight and bend your body forward – e.g. bending down while standing, bending forward in sitting with your legs out straight, or Downward Dog in yoga. Depending on how tight your hamstrings are, you can also stretch the proximal hamstring with the knee bent – e.g. pulling your knee into your chest or doing a deep lunge stretch. 2️⃣ Glute or piriformis stretches – these can sometimes also irritate the high hamstring tendons, especially if the tendons are very sensitive or if the way you pull happens to press them strongly against the sit bone. What to do instead 🙌 The best research-backed treatment for proximal hamstring tendinopathy combines relative rest with a graded, exercise-based rehab plan (strength work, not stretching). Other treatments can also be helpful, and we’ve discussed those in detail here . The main reason people want to stretch when they have proximal hamstring pain is usually because the hamstring muscles feel tight, sore, and uncomfortable. In that case, massaging those muscles might be a better option. This could be massage with a massage gun or foam rolling. Avoid applying strong pressure directly over the high hamstring tendons, as that can sometimes irritate them further. Maryke demonstrates how she foam rolls her hamstrings in this video: And here’s one for massaging your own glutes: How we can help 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. We're all UK Chartered Physiotherapists with Master’s Degrees related to Sports & Exercise Medicine or at least 10 years' experience in the field. But at Sports Injury Physio we don't just value qualifications; all of us also have a wealth of experience working with athletes across a broad variety of sports, ranging from recreationally active people to professional athletes. You can meet the team here . About the Author Maryke Louw is a chartered physiotherapist with more than 20 years' experience and a Master’s Degree in Sports Injury Management. Follow her on LinkedIn and ResearchGate .

In this article I discuss what compression socks are and how they work. I also take a closer look at the current research to find out if, like the manufacturers claim, they can truly help you perform and recover better. Some of the links are to pages where you can buy products discussed or mentioned here. We might earn a small commission on sales at no extra cost to you. In this article: How compression socks work Can compression socks improve your performance? Do compression socks help you recover quicker? Are compression socks able to prevent injuries? Some important things to consider How we can help How compression socks work Compression socks are thought to work in three ways: It improves your circulation As you know, your heart is the main pump that circulates your blood through your body. It pumps freshly oxygenated blood into your arteries, circulating it all the way to the tips of your fingers and toes. Thanks to the forceful action of the heart, it’s relatively easy for the blood to reach your limbs where your muscles and cells use the oxygen and nutrients in the blood. But it’s a lot harder work for the blood to find its way back to the heart again – especially if it has to flow up your leg against gravity. The further the blood is away from the heart, the weaker the pump-effect. That’s why the blood flows back to the heart through veins that have one way valves that stops the blood from running back down (it’s a bit like a canal system with locks). Your muscles (especially your calf muscles) can also act as pumps when they contract during exercise, helping to pump the blood back to the heart. Have you ever noticed how your ankles swell if you sit for a very long time e.g. on a bus or aeroplane? That’s because the lack of movement (muscles pumping) allows your blood and fluid to pool in your ankles and feet. Research have shown that graduated compression socks (that are tighter at the bottom and looser at the top) can increase your venous blood flow and stop the blood from pooling in your limbs. For athletes this may mean that they can recover faster as they would get rid of the waste products from exercise more quickly, their muscles would get more oxygen and that they would have less swelling in their muscles (exercise always cause a bit of swelling due to micro-trauma). It improves lymph drainage Compression garments also improve lymph drainage. Your lymph vessels transports waste products away from the cells and dumps it back into the blood so that it can be excreted in your urine. If you can improve your lymph drainage you can usually also improve recovery and healing. It protects your muscles It has also been suggested that compression garments may help to protect muscles during exercise by reducing the impact forces on the muscles which in turn helps to reduce exercise induced inflammation, swelling and muscle damage. So in theory, compression socks seem to potentially hold a lot of benefit for athletes but what does the research say? Do they provide any clear performance and recovery benefits when tested on athletes? Can compression socks improve your performance? The research is not very clear on whether compression garments can improve performance. It appears that different athletes may benefit in different ways from compression socks. Here are some of the findings: Slower athletes may benefit more from a circulatory effect In studies where they looked at blood flow, it was shown that compression socks improved the blood flow in the calf but only when participants exercised at a very low level e.g. walked slower than 6km/hour or cycled at less than 120W. Their circulator systems did not seem to gain anything from wearing compression socks when they exercised at higher intensities. Remember that I mentioned above that the calf muscles, when they contract, can act as a pump to pump blood back to the heart? The researchers think that this calf-pump effect becomes so efficient when you exercise at higher intensities that compression socks don’t really offer any additional benefits to the circulatory system. Runners A group of researchers recently collected all the studies performed on runners to see if wearing compression stockings while running held any benefits for them. They found that it did not seem to influence running performance (times for a half marathon, 15-km trail running, 5- and 10-km runs and 400-m sprint), oxygen uptake, blood lactate concentrations or heart function. They did, however, find some positive effects. Time to exhaustion (how quickly the runners got tired) and running economy were improved in the group of runners that wore the compression socks while their blood markers also showed that they had less muscle damage and inflammation after exercise. Football players Full length compression tights (compared to shorts or socks) were found to work best to reduce the amount of muscles damage and inflammation that players sustained during a match.  So if your aim is to reduce muscle damage during exercise, you may want to consider wearing more comprehensive compression garments than just socks. The compression tights below looked like good value for money when I searched on Amazon. But I must admit that I prefer to just wear compression calf sleeves in the summer. Do compression socks help you recover quicker? Yes, the research is a lot clearer on the benefits that compression garments hold for recovery. DOMS Multiple studies have shown that compression socks can reduce the pain you feel after exercise (DOMS). This is most likely due to it allowing you to get rid of waste products more quickly. There is strong evidence that shows that compression socks improves your circulation to your muscles if you wear them after exercise or at rest. Fatigue Athletes who use compression garments consistently report feeling less tired during recovery. Strength, power, endurance A common way to test how long an athlete takes to recover is to see how long it takes them to regain their full strength, power and endurance that they had before the training session or competition. Athletes who use compression garments appear to show a quicker recovery for strength and power and to a lesser extent endurance when compared to athletes who don’t wear them. Type of exercise It seems that the more damaging the exercise is, the greater the recovery benefits are that you’ll get from wearing compression socks or tights. For instance, a much greater recovery effect has been found after strength training versus running or cycling. The products below get good reviews on Amazon. Again, I prefer the calf sleeves because I like to wear my own socks. Are compression socks able to prevent injuries? We don’t know yet. I could only find one study that tried to investigate this, but it was unfortunately not a very good study. The researchers sent out a questionnaire to 203 trail runners and asked them about their training, if they used compression socks when training and how many injuries they accumulated during the season. They found that the group of trail runners who wore the compression socks while training reported significantly fewer injuries. The problem with this research is that we can’t really tell if this difference was purely down to the compression garments as it could just as easily have been down to training, fitness or experience. Some important things to consider More is not always better. Compression socks that are too tight can actually cut off your circulation and have the opposite effect. Researchers have found that compression socks don’t always produce the amount of compression that they claim to provide even if you select them according to the manufacturer’s guidelines. Differences of between 3% and 20% from the target pressure has been reported. I would suggest that you don’t worry too much about it. Select the size according to the manufacturer’s guidelines and make sure that they feel firm but not uncomfortable when you wear them. They’re too tight if they cause your muscles to cramp or hurt. If you spend a lot of time standing during the day, you may benefit more from compression socks than other athletes. Gravity will make it much harder for your blood to flow back to your heart and compression can help you overcome this and recover better. Varicose veins affects your circulation and tends to allow your blood to pool more in your limbs. This means that athletes with varicose veins will likely benefit more from compression socks than others. How we can help Need more help with an 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 Maryke Louw is a chartered physiotherapist with more than 20 years' experience and a Masters Degree in Sports Injury Management. Follow her on LinkedIn or ResearchGate . References Brown F, Gissane C, Howatson G, et al. Compression garments and recovery from exercise: a meta-analysis. Sports Med 2017;47(11):2245-67. Dupuy O, Douzi W, Theurot D, et al. An evidence-based approach for choosing post-exercise recovery techniques to reduce markers of muscle damage, soreness, fatigue and inflammation: a systematic review with meta-analysis. Frontiers in physiology 2018;9:403. Engel FA, Holmberg H-C, Sperlich B. Is there evidence that runners can benefit from wearing compression clothing? Sports Med 2016;46(12):1939-52. Hill J, Howatson G, van Someren K, et al. Compression garments and recovery from exercise-induced muscle damage: a meta-analysis. British Journal of Sports Medicine 2014;48(18):1340-46. doi: 10.1136/bjsports-2013-092456 Hill J, Howatson G, van Someren K, et al. PRESSURES EXERTED BY COMMERCIALLY AVAILABLE LOWER LIMB COMPRESSION GARMENTS. British Journal of Sports Medicine 2014;48(7):608-08. doi: 10.1136/bjsports-2014-093494.131 Lee DC, Lee SW, Khaw K, et al. Haemodynamic responses of wearing low-pressure sports compression tights during an orthostatic challenge in healthy individuals. Journal of Science and Medicine in Sport 2017 Marqués-Jiménez D, Calleja-González J, Arratibel-Imaz I, et al. Influence of different types of compression garments on exercise-induced muscle damage markers after a soccer match. Research in Sports Medicine 2018;26(1):27-42. Ménétrier A. THE USE OF THE ELASTIC COMPRESSION TO DECREASE THE RISK OF INJURY. British Journal of Sports Medicine 2014;48(7):638-38. doi: 10.1136/bjsports-2014-093494.211 Peseux M, Muzic J, Bouhaddi M, et al. Changes in Tissue Oxygen Saturation with Well-and Tight-Fitted Compression Sleeves During an Incremental Exercise on Treadmill. Asian Journal of Sports Medicine 2017;8(4) Stanek JM. The effectiveness of compression socks for athletic performance and recovery. Journal of sport rehabilitation 2017;26(1):109-14.

Yes, (most) injuries cause pain. But the severity of the pain is not linked to the severity of your injury, and sometimes pain can persist long after an injury has healed. Learn how pain is created and how to use this to guide your injury recovery. Remember, if you need help with an injury, you're welcome to consult one of our physios online via video call. In this article: A new understanding of how pain works Why and how pain is created A typical pain response Why pain can get dialled up How to use pain science to help recovery How we can help A new understanding of how pain works We used to think that pain was quite simple: You have pain receptors everywhere in your body, you get injured, it triggers the receptors, and that creates the pain. And the more severe your injury is, the more painful it is. Thanks to recent advances in the field of scanning and interpreting injuries inside our bodies, we now know that there is not necessarily a link between how bad an injury is and how much pain we experience. There have been many instances of people whose scans showed severe injuries while they experienced very little or no pain. Also, people without injuries (or whose injuries have healed completely) who had extreme pain. And of course, sometimes the pain reacts like we expected it to in the “old days”: You have an injury, and it’s painful. As the injury heals, things get better, and the pain goes away totally. ❓ So, why does that happen in the expected way for some people while for others there seems to be a disconnect between the pain and the injury? Why and how pain is created What we now understand  about the nervous system is that we don’t have “pain receptors”. What we do have is sensors that are constantly measuring things that could potentially affect our tissue health. These are things like pressure, stretch, chemicals, and temperature – some of which are present all the time. And these sensors are constantly sending our subconscious brain messages or signals about these. Obviously, your brain would go haywire if it were to react to all these messages, so there’s a threshold above which it goes “Hey, this seems like it could be dangerous to the body I’m inhabiting!” It then creates pain because it wants you to take action to reduce those signals. 👉 It is important to note that this is your subconscious at work here – you have no direct control over it. That is why “mind over matter” is not a way to deal with pain, and in fact, that approach might even increase your pain. However, this is also not to say that pain is “all in the mind” – your body undergoes actual physical changes in reaction to it. A typical pain response When you’re injured, your subconscious brain goes into “protection mode” and lowers the threshold at which it creates pain – this is to ensure you take extra care with the injured part, which, in theory, should allow it to heal more quickly.   For example, you can squeeze your thumb as hard as you like when it’s not injured, and it doesn’t really hurt. But let’s say you’ve just hit it with a hammer – even the most gentle squeeze can cause very strong pain. Such a gentle squeeze is obviously not strong enough to cause damage – it’s just the pain system being on high alert and telling you to “be careful please!”. 👉 So, it’s normal for an injured area to be painful and to experience discomfort during your recovery period. Just because a rehab exercise or movement is causing a bit of discomfort, does not necessarily mean it is making things worse – it is likely just the alarm system firing off an early (and maybe unnecessary) warning. Every injury is different and will have very specific requirements for what activities you’re allowed to do and how much pain is expected and OK to experience during rehab. We discuss this in detail for each type of injury elsewhere on our website, so I am not going to go into those details now. And of course, we specialise in creating very individualised rehab programmes for our patients that take their personal pain-and-rehab circumstances into account. If this is what you’re after, consider booking a video call  with one of our physios. In an ideal world, if you stay within the rehab and pain parameters of what your physiotherapist or doctor has prescribed, the injury will heal and the pain system should return to normal in line with this. But of course, few things work perfectly in real life, so often the pain system can get a bit oversensitive and cause more pain than it should – higher intensity or simply just more persistent low level, annoying discomfort. Why pain can get dialled up The signals from the sensors are not the only things that determine whether and to what extent your subconscious creates pain. There are other factors at play that could make your subconscious interpret these signals as more dangerous or less dangerous than what they are conveying and which, in turn, make your subconscious dial the pain up or down accordingly. Here are some examples. Often, several of these factors combine to sensitise the pain system. Oh, and this is not an all-or-nothing situation – most of us will have a mix of true injury-related pain and some "extra" pain (sensitivity) – an experienced physiotherapist can help you understand your situation and help pitch your rehab at the right level to allow it all to calm down. Physical changes to the pain system “hardware” If you’ve had pain or an injury in a specific area for several weeks, you develop more of those little sensors, and they get triggered more easily and fire off more messages to the brain.   📢 So, your body becomes better at creating the signals that trigger a pain response. It’s as if the body feels you’re ignoring it, so it wants to make more noise to get your attention. 👍 But the good news is that, if you provide your body with the correct level of activity and rehab and work on the other elements mentioned below, it reverts these physical changes back to normal. If you've had pain for several weeks, your body undergoes physical changes that makes it better at creating pain. Past experiences with pain If your past experience of, say, a running injury tells your subconscious brain “Nah, that type of pain goes away quite quickly, I just have to have a couple of days of rest, then I can run again” it's not going to pay that much attention to that area, and your pain will just calm down as the tissue calms down. However, if the last time you had pain in that area meant that you were not be able to run or exercise for six months to a year, it is going to pay heavy attention to it, and it's likely going to create more pain than how severe the actual injury is. Your past experiences with injuries and recovery outcomes and what you believe about the severity of an injury can dial your pain up or down. If your father has had bowel cancer and you suddenly get pain in your stomach, your subconscious brain might go “Oh shucks, Dad had bowel cancer! Now my stomach's hurting. It might be bowel cancer!” and it might create more pain than is warranted. There have been experiments where they've measured people's pain before they see a doctor, then they see the doctor, and they get a diagnosis that the injury is not serious. When they then measured the pain immediately afterwards, and it has decreased by nearly 50% on average. Obviously, no physical healing has taken place during the consultation, but the subconscious brain has been reassured that the injury is not as dangerous as it had thought it was. Social media can be a problem These days, it’s very common to google an injury or join online communities (such as Reddit or a Facebook Group) to research and discuss injuries. And yes, this can be very useful. However, the voices in these groups are often extremely polarised, creating a negative expectation about recovery. People don’t usually look for, or join, online communities when their recovery is going as expected. Instead, these spaces often gather a high concentration of people who, unfortunately, haven’t recovered as expected and continue to struggle. The message is often: “This injury will never get better – I’ve had it for x number of years.” This message can get stuck in people’s minds, shaping what they believe. That can heighten their subconscious perception of how severe the injury is and keep their symptoms dialled up. There is a lack of positive injury recovery stories in social media communities. It’s natural to look for support from others who can relate to your situation, and this type of support can be very helpful. I’m not saying you should avoid it. But it’s important to remember that every person is different. We all have unique circumstances – stress, fear, genetics, and many other factors – that can affect recovery. One person’s reality does not have to be yours. 👉 If the people you interact with (online and off) often make you feel that you’ll never recover, it might be time to look for a different community. Those thoughts are very likely to sensitise your pain system and might increase or cause persistent pain. Words I (and other healthcare professionals) use There is strong evidence that the belief someone has about their injury (how severe or serious it is, how likely it is to recover, etc.) can influence the intensity of their pain. It can also make them avoid activities unnecessarily because they expect them to hurt or cause problems. Terms like “wear and tear” or “degeneration” are often used when clinicians talk about arthritis or tendinopathies (e.g. degenerative tendinopathy). But these terms can make you picture that area of your body as being worn out, which can then easily lead to thoughts like, “Well, that must mean that it will only get worse and never recover.” In a recent study, a group of researchers tested this concept on 50 Achilles tendinopathy patients. They divided the participants into two groups who followed the exact same rehab plan. The only difference was that: one group was given a very detailed explanation of the injury process, including medical terms like “degenerative tendinopathy,” while the second group was told their tendons were just irritated and sensitive due to being overworked and therefore not able to tolerate as much training at the moment, but that the rehab plan would allow the sensitivity to settle and restore the tendon’s exercise capacity. (I paraphrased what they said) At the end of the trial, the second group reported significantly less pain than the other group, despite following the same rehab plan. This is just one example of how well-intended advice can backfire. Our team always try hard to use words that we think are unlikely to cause unhelpful beliefs, but it is really difficult to anticipate how someone might interpret them. 👉 The best way we’ve found around this is to build a good rapport with our patients and take time to listen to them and discuss their beliefs. This is one of the reasons why we take so much time during our video consultations to really talk the situation through. Emotions such as stress and fear Stress (work, family, life) and fear cause the body to release stress hormones. These can cause the pain to be dialled up or down. In the short term, when you experience a high-stress crisis situation, your subconscious might dial down the pain to allow you to deal with a dangerous situation. This is why some people in car accidents have been able to rescue fellow victims in dire need of help while they themselves had a broken arm or leg, and only hours later do they realise they have broken something. But if those stress hormones are elevated for days on end, your subconscious brain starts to increase the pain response. For instance, if you fear that your injury is going to prevent you from continuing to earn a living and provide for your family, the pain might get dialled up to way beyond what the physical nature of the injury warrants. If you're a strong-minded person who is inclined to “get on with it and get things done”, it can be annoying when somebody tells you “But your brain and your thoughts and your feelings can contribute to this pain experience.” 🤔 And their first reaction – mine too – is typically to rebel against that. But the research shows that it's the Type A personalities – perfectionists and high-achievers who tend to be able to get on with things and who like high-stress situations – who tend to suffer more with ongoing pain. A disconnect between your brain and the injured limb Using MRI scans, the people in the white lab coats have figured out which part of your brain lights up when you move, say, your leg or even when you just think about your leg – and it’s the same part of the brain – on the opposite side – for either leg. They have found that for people with persistent injuries that last for several months (say, an injury to the right ankle), the brain doesn’t light up in the same way anymore that it lights up for the left ankle. The area that lights up for the injured or painful side is smaller, and it looks like the uninjured side becomes more prominent. They’ve also found that, as chronic injuries or pain starts to improve, the brain’s representation of that area becomes closer to normal. This has led them to speculate that the subconscious brain has started to disregard that limb as a part of the body, which might contribute to the pain being dialled up. 👉 The good news is that they’ve also identified very simple techniques that can help to get things back to normal. I share them in the sections below. 💡 In summary, pain is often being dialled up because your pain system has become “too good” at protecting you. So, how do we reverse this? How to use pain science to help recovery Don’t push through pain If you ignore your pain and continue training or repeatedly doing activities that significantly irritate your symptoms above a certain level, the subconscious feels that you’re not taking it seriously and usually amplifies the pain. So, the first step should always be to consult your doctor or physiotherapist and have your injury diagnosed so you know what you’re dealing with. They can then also help you understand what the correct level of activity and expected pain levels are that will allow your body to recover while also calming the pain system down. Consulting a physiotherapist can help you understand what the best level of activity is in your case. Movement is important Some injuries (like fractures) might require that you rest the area completely for a period of time. But it’s really important not to over-protect your injury and limit activity unnecessarily. There’s evidence to show that over-protecting and injury causes the subconscious brain to think more and more of that area of the body as “not part of your body”. 👍 So, a big part of “reclaiming” your injured body part and connecting it to your brain again is to start moving it. This is why we try and keep our patients as active as possible within their safe limits. Where people often go wrong at the start of their rehab is to think they should really push it. You don't have to. If it's really painful, you just start with what it can do without too much pain. Your physio will help you to understand what the best activities and exercises are for the type of injury you've had. “Mindful” exercise Now, I'm very aware of how airy-fairy the term “mindful exercises” sounds, but hear me out. Remember how I said that MRI scans show how your brain starts to light up differently for an injured limb? Researchers have found that you can change how the brain lights up back to normal simply by paying attention to the limb rather than ignoring and overprotecting it. At some point in your recovery, you will very likely be prescribed rehab exercises. Rather than watching TV while you are doing your exercises, you should switch off the TV and think about what you’re doing – pay attention. Some things that have been shown to be useful include: Looking at your injured limb while you move it, Observing what you feel and how it moves, and Really trying to control the movements properly – slowing the movement down can be very effective for this. If it’s an exercise for your arm, this is your way of telling your subconscious brain “This is my arm. We are moving my arm. And see, it is okay to move my arm.” 💡 In some research studies, they ask patients to move their injured limb to the beat of a metronome or to slow the movement down and focus on moving for "x" seconds in one direction before switching. The method isn't important – what matters is that, by having to match a rhythm, the brain is forced to pay attention, and this improves its control over the limb. Self-talk Self-talk has to do with all those thoughts and worries that pop into your head throughout the day, but also while you're doing your exercises and doing your activities. Identify all those negative thoughts – all the fears. They might be legitimate fears, but identify those creeping thoughts and feelings that are making you more worried. That little voice that's sitting here on the shoulder – get it to shut up. And don't just tell it to shut up. Reason with it. Explain to it that “No, it will be okay. It’s going to take time, but it will gradually calm down.” It doesn't like to just be ignored or told to shut up; you have to “convince” it by providing "evidence". Another way to counter those negative thoughts is by taking time to reflect on how far you’ve come. It’s easy to feel that “you’ll never get better” if you focus on how far you are from where you want to be. Whenever I’m injured, I force myself once a week to take a few moments to reflect on what I can do this week that I couldn’t do two weeks ago – sometimes it’s just that I can now walk to the shop without as much pain or slightly faster than before – that is progress and a sign that my body is recovering. This is another reason why it is useful to work with a physiotherapist – they can help you understand what the expected recovery time is for your specific case and whether you’re recovering as expected. They are also great at helping you to acknowledge your progress. Pain psychologists and sports psychologists can also help – they often have clever techniques to help with the mental side of injury recovery. As cheesy as it sounds, you have to replace those negative voices with positive ones. Breathing Why breathing? It's the most effective way they have found so far to get your vagus nerve to calm down. The vagus nerve is in charge of your fight-or-flight reaction or your stress response. And if you can get the vagus nerve to calm down, it actually helps your stress hormone levels to calm down, and that can desensitise your pain system. So, we’re talking slow, deep breathing – the kind that makes your belly move in and out. You don't have to get fancy about it. Just every now and again, tell yourself to breathe. You can approach this in two ways or use both. First, make sure that you breathe deeply while you are doing your rehab exercises and focus on relaxing as you do it. But you can also have one or two sessions a day where you just do deep breathing for a few minutes. You could stick on a YouTube video about yoga where they teach you about breathing and just follow along. Massage There's good evidence  to show that touch and massage can decrease pain and desensitise nerve endings. And research has shown that that touch or massage that comes from a loved one works even better. But when you have an injury that's extremely painful and you can easily reach it, rather start off by doing it yourself, because your subconscious brain trusts you more than anyone else. What’s important is that the massage (regardless of who is doing it) should be at a comfortable or “comfortably uncomfortable” level. A very painful massage might further sensitise the pain system and cause a flare-up of pain several hours later. And some injuries should not be massaged, so check with your physiotherapist before you do anything. 💡 Massage is not appropriate for all injuries, so please check with your physio before you do it. Heat and cold Both heat and cold therapy can be useful for calming the pain system, but they are not appropriate for all injuries. You can read a detailed explanation of when/how to use ice or heat for sports injuries here. Acupuncture or dry needling In my experience, acupuncture usually doesn’t work if the person is scared of needles. I think this is because, when you're scared of it, it actually increases your stress hormones and cause your pain to feel worse. But if you're not bothered by needles, acupuncture or dry needling is something that could be useful to decrease pain. However, it doesn't work for everybody, and you shouldn't have it just for the sake of having it. If you've gone for three or four needling sessions and you haven't seen improvement, it's likely not going to work for you, and it's not worth spending money on more of the same. How we can help 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. We're all UK Chartered Physiotherapists with Master’s Degrees related to Sports & Exercise Medicine or at least 10 years' experience in the field. But at Sports Injury Physio we don't just value qualifications; all of us also have a wealth of experience working with athletes across a broad variety of sports, ranging from recreationally active people to professional athletes. You can meet the team here . About the Author Maryke Louw is a chartered physiotherapist with more than 20 years' experience and a Master’s Degree in Sports Injury Management. Follow her on LinkedIn and ResearchGate . References Shawn L. Hanlon, Ryan T. Pohlig, and Karin Grävare Silbernagel (2021) “Beyond the Diagnosis: Using Patient Characteristics and Domains of Tendon Health to Identify Latent Subgroups of Achilles Tendinopathy” Journal of Orthopaedic & Sports Physical Therapy 2021 51:9, 440-448 Butler, D. and Mosely, L. (2013) “Explain Pain – Second Edition” Noigroup Publications: Adelaide, South Australia. Mak S, Allen J, Begashaw M, et al. (2024) “Use of Massage Therapy for Pain, 2018-2023: A Systematic Review” JAMA Netw Open. 2024;7(7):e2422259

Sports physio Maryke Louw demonstrates glute bridge exercises, including the following glute bridge variations: double-leg glute bridge, offset glute bridge, marching glute bridge, and single-leg glute bridge. She also explains the benefits of glute bridges as well as glute bridge progressions once you have mastered the basic stuff. Remember, if you need help with an injury, you're welcome to consult one of our physios online via video call. Some of the links in this article are to pages where you can buy products mentioned here. We might earn a small commission on sales at no extra cost to you. In this article: Glute bridge benefits Glute bridge mistakes How many bridges should I do? Glute bridge progressions (how to make them harder) Glute bridge variations demonstrated How we can help We've also made a video about this: Glute bridge benefits   The glute bridge is a compound exercise that strengthens your : Back muscles (erector spinae and multifidus) Stomach muscles (rectus abdominus and obliques) Gluteal or buttock muscles (gluteus maximus, gluteus medius, gluteus minimus) Hamstrings (back of thigh muscles).   It can also help to actively stretch your hip flexor muscles  (over the front of your hips): Iliopsoas Rectus femoris (one of the quadricep muscles). Glute bridge mistakes   ❌  Lifting too high (over-arching your back): Overworks your back muscles and reduces your glute activation Can cause back pain Can strain your neck 👍How to fix it: Focus on driving the movement by squeezing your buttock muscles  rather than using your back. Contracting your stomach muscles at the same time also helps – it’s impossible to over-arch your back with your stomach muscles contracted.  ❌ Letting your hip drop  when you lift a leg or do single-leg bridge exercises: Can cause your back to strain Means that you’re not strong enough to control the rotational force when supported on one leg 👍How to fix it: Choose a slightly easier version  of the bridge to work on first Or concentrate on really tightening your glutes and core  before lifting the leg and on keeping them contracted as you lift Pressing your elbows and upper arms into the floor  while doing the exercise activates your posterior chain (latissimus dorsi and glutes), which can increase your control How many bridges should I do?   This will depend on whether you’re doing them as isometric bridges (where you hold the position for several seconds before resting)  or simply lift up and down several times before resting (isotonic bridges) .   Isometric bridges: Start with short holds and more repetitions, e.g. 10-second holds x 10 repetitions. Build up to longer holds and fewer repetitions, e.g. 30-second holds x 4 repetitions. Rest between the repetitions for at least as long as you hold each contraction.   Isotonic bridges: Do sets of 10 to 15 repetitions. Do 3 sets. Rest 1 to 2 minutes between sets.   When you can easily perform the suggested dose with good form, it’s time to progress and make them a bit harder. Glute bridge progressions (how to make them harder)   You can make each type of bridge harder by: Placing a weight across your pelvis (works all the muscles harder) Pulling an exercise band  apart with your thighs while bridging (works glute med harder) Holding the position for longer when doing isometric bridges Doing more repetitions or sets Or moving on to the next type of bridge in the list below.   Glute bridge variations   You can easily make the exercise harder or easier without the need for fancy equipment by adapting your glute bridge position. I've listed the progressions in order of increasing difficulty.   Make sure you master each type properly before moving on to the next.   1. Double-leg glute bridge This is a good one to start with to learn proper bridging technique. 📽️ Play video demo Instructions: Lie on your back with your knees bent 90 degrees. Tighten your tummy muscles. Squeeze with your glutes (not your back muscles) to lift up your hips – just to where they naturally stop. Come back down slowly. Top tips: Place your feet on a low step to work your glutes through a larger range of motion and/or if your hips don't want to go up very far. If your hamstrings cramp , place your feet closer to your bum.   2. Offset glute bridge This type of bridge allows you to work one leg slightly harder than the other . It helps to build the strength needed for single-leg bridges. 📽️ Play video demo Instructions: Lie with both knees bent to about 90 degrees. Then slide one foot slightly further away from your bum so that leg is a bit straighter. Tighten your stomach muscles and then squeeze your glutes to lift up into the bridge position. The leg that is more bent (foot closer to your bum) should be doing most of the work. Your hips must stay level. Pause for a moment at the top. Come back down slowly. Complete a full set with one leg closer to your bum. Rest for 60 seconds. Then repeat with the other foot closer to your bum. Do 3 sets on each leg (6 in total). Top tip: If you find that your hips do dip to one side, don't come down right away; correct the position before you come down.   3. Marching glute bridge Marching bridges help you to develop control , so you’re able to keep you back and pelvis stable when switching from double to single-leg support. 📽️ Play video demo Instructions: Go into the elevated double-leg glute bridge position (see instructions above). Check that you're squeezing your core and glutes. Lift one leg up, ensuring that your hips stay level and don't dip lower. Pause for a moment. Bring the leg down slowly. Repeat with the other leg. Do 10 to 16 repetitions (alternating legs). Rest 1 minute. Do 3 sets. Top tips: Press with your elbows into the floor for better stability. Again, if your hips tilt or dip while a leg is lifted up, correct your form before bringing the leg down. Take a brief rest between reps if you find that you're losing your form towards the end of a set. 4. Single-leg glute bridge Doing glute bridges on one leg at a time ensures that you work each leg equally hard . It also requires good strength and control in your core muscles. 📽️ Play video demo Instructions: Lie with your knees bent to 90 degrees and feet flat on the mat. Lift one leg towards you so that the thigh is tucked against your stomach. Tighten your stomach muscles and squeeze your glutes to lift you up. Keep your hips level, correcting your position if necessary before coming down. Complete a full set on one leg before switching legs. Rest 30 to 60 seconds between sets. Top tips: Press with your elbows into the floor for better stability. If your hamstrings cramp , stretch them for a bit before continuing. It can also help to move your feet closer to your bum. How we can help Need help with an 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. We're all UK Chartered Physiotherapists with Master’s Degrees related to Sports & Exercise Medicine or at least 10 years' experience in the field. But at Sports Injury Physio we don't just value qualifications; all of us also have a wealth of experience working with athletes across a broad variety of sports, ranging from recreationally active people to professional athletes. You can meet the team here . About the Author Maryke Louw is a chartered physiotherapist with more than 20 years' experience and a Master’s Degree in Sports Injury Management. Follow her on LinkedIn and ResearchGate . References Bourne, M. N., Williams, M. D., Opar, D. A., Al Najjar, A., Kerr, G. K., & Shield, A. J. (2016). "Impact of exercise selection on hamstring muscle activation"  British Journal of Sports Medicine . Ebert, J. R., et al. (2017). "A Systematic Review of Rehabilitation Exercises to Progressively Load the Gluteus Medius" Journal of Sport Rehabilitation 26(5): 418-436. Yoon, J. O., Kang, M. H., Kim, J. S., & Oh, J. S. (2018). "Effect of modified bridge exercise on trunk muscle activity in healthy adults: a cross sectional study"  Brazilian Journal of Physical Therapy ,  22 (2), 161-167. Kim, C. M., Kong, Y. S., Hwang, Y. T., & Park, J. W. (2018). "The effect of the trunk and gluteus maximus muscle activities according to support surface and hip joint rotation during bridge exercise"  Journal of Physical Therapy Science ,  30 (7), 943-947.

Whether or not to use ice for a hamstring tendinopathy is a hotly debated topic. We explain how this came about and why it is fine to use ice to get relief from the debilitating pain that high hamstring tendinopathy can sometimes cause. Remember, if you need more help with an injury, you're welcome to consult one of our physios online via video call. This article contains affiliate links. We might earn a small commission on sales at no extra cost to you. In this article: Arguments for and against ice for high hamstring tendinopathy (Mis)interpreting the research Why and how you can use ice for a hamstring tendinopathy How we can help We’ve also made a video about this: 👉 Read more about other aspects of high hamstring tendinopathy here . Arguments for and against ice for high hamstring tendinopathy Most people who have had high hamstring tendinopathy will tell you that it is an extremely painful condition, and that sitting is especially challenging and painful. It is generally known that ice can be used for pain relief for many types of sports injury. Many of my high hamstring tendinopathy patients have found that sitting on ice or applying ice when the pain gets very bad gives them some much needed comfort and relief. However, there are many people on the Internet who argue against ice for this condition and other sports injuries. They say that ice prevents or inhibits inflammation , and that inflammation is necessary for healing to take place. Therefore, the argument goes, using ice for a painful high hamstring tendinopathy will slow down your recovery process. (Mis)interpreting the research The problem is that the anti-icers are taking research that has very little to do with high hamstring tendinopathy pain relief and healing and using it to “prove” their point. The research they are referring to has been done on uninjured professional cyclists and other high-level athletes to see whether full-body immersion in ice baths directly after training sessions is beneficial or detrimental to the training effect on their bodies. It makes sense to research this, because inflammation also plays a role in recovery after exercise. Some of these studies found that this way of using ice after exercise does indeed inhibit inflammation and decreases (but doesn’t totally nullify) the positive training effect, whereas other similar studies found that it had no detrimental effect. 💡 But the inflammatory response after exercise is a very different process to the injury process involved in ongoing hamstring tendinopathy. It’s like comparing apples 🍎 and orangutans 🦧 – they’re not even in the same category. Why and how you can use ice for a hamstring tendinopathy First, a tendinopathy is an injury that has been going on for several months or more, so there is very little or no inflammation for the ice to inhibit. Read more about the difference between tendinopathy (no inflammation) and tendinitis (lots of inflammation) . Also, icing a high hamstring tendinopathy is about pain relief, not the influence it might or might not have on training effects after exercise (rehab exercises, in this instance), as we shall see below. Pain vs. progress With high hamstring tendinopathy, pain can really ruin your progress much more than a bit of ice can. Pain stops you from moving, pain stops you from going for walks, pain stops you from sitting down, pain can stop you from doing your rehab exercises. So, if ice is effective at bringing your pain levels down so that you can move more and do your rehab exercises properly, it is a no-brainer to use it, and it might indeed contribute to a faster recovery. No ice baths Unlike in the research studies mentioned above, none of our high hamstring tendinopathy patients are getting into an ice bath. The ice is applied only to the painful area, so the hamstring muscles aren’t affected at all. Timing might matter If you are still concerned that applying ice to your injured high hamstring tendons will inhibit the training effect of your rehab exercises, then don’t apply it after you’ve done your exercises. Also, if your pain shortly after having done your rehab exercises is so severe that you need ice for it, the exercises are probably too challenging for the stage of recovery you are in. Rather apply the ice when you really need pain relief and any "beneficial" inflammation is totally out of the picture, e.g. after you have had to sit for an extended period of time or had to drive a long way. How to apply ice Don’t apply the ice pack directly on your skin – place a towel or something similar between the ice and your skin. And remember, our bodies function best at a temperature close to 37 degrees Celsius. So, you don’t want to go overboard with the ice and sit on it all day long 🥶 – that could be counterproductive. 💡 Instead, apply the ice for 10 minutes, remove it and wait 10 minutes, and apply it for another 10 minutes. This is one session. You can do up to three sessions per day. 👉 This article of ours has some more detailed guidance on how to use ice for injuries . How we can help 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. We're all UK Chartered Physiotherapists with Master’s Degrees related to Sports & Exercise Medicine or at least 10 years' experience in the field. But at Sports Injury Physio we don't just value qualifications; all of us also have a wealth of experience working with athletes across a broad variety of sports, ranging from recreationally active people to professional athletes. You can meet the team here . About the Author Maryke Louw is a chartered physiotherapist with more than 20 years' experience and a Master’s Degree in Sports Injury Management. Follow her on LinkedIn and ResearchGate .