with Mark Elmes, Chartered Physiotherapist, CSCS
twitter: @mark_elmes
Pain in the derrière (we call it the posterior hip) can be an alarming and worrying sensation. We have dreaded connotations that it’s our back or hip joint. This feeds into our fear of the dreaded “bad back.” It’s a fear we’ve all had at some point so we understand your worries. However, what if I told you that this pain may not be related to your back at all? What if I told you that this pain doesn’t mean protection and rest? Let me paint a picture for you…
Proximal hamstring tendinopathy refers to an overload injury to the origin of your hamstring muscle where it begins in your pelvic bones. We’ll discuss what’s going on in the tendon later on but for now let me continue painting the picture. It’s a persistant tricky pain to resolve because it’s very easy to aggravate it. We know that compressive load makes it worse (Pope and Goom, 2016). In this movement pattern the hamstrings are working as your knee is bent which squashes the tendon. Unfortunately this involves many movements that we need to complete daily: sitting, driving, lunging forward, stretching the muscle and walking/running uphill. The pain is local, meaning it is fairly pinpoint in the buttock at the tendon site. Finally it is typically worse in the morning and warms up throughout the day in the early to middle stages. If the tendinopathy becomes more advanced then the pain can persist. If this is sounding familiar then there’s a strong chance it’s not your back. If it’s not please don’t be alarmed and worried about your back (we’ll discuss this in the coming weeks).
It’s important now to delve into the science behind tendon problems as the understanding of it is an essential component of being able to address these. We used to call them tendon-ITIS, meaning inflammation of the tendon. However as we worked on improving these persistant issues we discovered graded exercise helped much better than rest. We looked a little further at a cellular level and at lots of expensive imaging and there was very little true inflammation at all. It became apparent that the tendon was degenerated due to overload (Cook and Purdam, 2014), its foundations for function not in perfect harmony. There will be an evident history that we can help identify at this point. In simple terms the mechanical organisation of the tendon has become disorganised and all the concurrent activity on the tendon continues the path of disrepair and the body can’t catch up (Magnussen et al, 2008).
So if the body can’t catch up then surely we should rest it and allow it to catch up and heal? It’s a fair point but widely agreed to be incorrect. Tendons are marvellous structures that strictly adhere to the body’s use or lose it principle. They adapt to the demands we place on them (Bohm et al, 2015). Therefore if we don’t exercise them, we won’t improve their health and function. We simply need to hit a sweet spot in terms of exercising and load that is best completed in conjunction with a chartered physiotherapist with an interest in these problems. This means you can continue your sport at a reasonable level and life remains much more enjoyable.
Now for some practical advice. This problem requires a much more precise and focused management than other differential diagnoses that one may encounter. We strongly recommend you seek a qualified opinion on this before addressing this pain so you can get on the right path. Firstly, DO NOT STRETCH. Trust us on this one. Secondly, AVOID COMPRESSION where possible. This means don’t bend over too much, sit for too long and think about what increases your pain a little more. Thirdly, MANAGE YOUR LOAD (Pope and Goom, 2016). You’ll need help on this but we need to strike a balance between maintaining your exercise habits and not continuing this overload. We hope now that you realise all is not lost and we can improve your quality of life with some very attainable strategies.
Now for the important bit… We won’t delve too much into it but please take our words as gospel – EXERCISING THE TENDON IS VITAL (Khan and Scott, 2009 and Bohm et al, 2015). The trick is to find the appropriate level and take it from there. We know loading the tendon is by far the best way to improve its mechanical properties. We’ll be uploading a nice early isometric exercise from early next week. This will help reduce your pain in the early stages. Please note it may not suit everyone and a lot of times we need to adapt these for the individual. We recommend seeking professional help with this.
As always the latter stages of rehab are more complicated and we could write pages about it. Also we don’t want to ruin your weekend by boring you if we don’t have to.
If this problem is all too familiar we would urge that you consider seeking help. We love taking to people about all of the above and would be glad to help. Everyone is unique and the reasons for your hamstring developing this can be very different to another individual. It’s very important therefore to identify it and address it specific to yourself. Don’t let it it persist!
If you require further information or would like to speak with one of our physios, please call 046 9062265 or email info@mcenteephysio.com
References
Bohm, S, Mersmann, F, Adamantios Arampatzis, A. (2015). Human tendon adaptation in response to mechanical loading: a systematic review and meta-analysis of exercise intervention studies on healthy adults. Sports Medicine. Vol. 1(7)
Cook JL, Purdam, CR. (2014). Is tendon pathology a continuum? A pathology model to explain the clinical presentation of load-induced tendinopathy. BJSM. Vol. 43; 409-416
Kaux, JF, Forthomme, B, Le Goff, C, Crielaard, JM, Croisier, JL. (2011). Current Opinions on Tendinopathy
Journal of Sports Science and Medicine. Vol. 10(2); 238–253.
Khan, KM< Scott, A (2009). Mechanotherapy: how physical therapists’ prescription of exercise promotes tissue repair. BJSM. Vol. 43;247–251.
Magnusson, SP, Narici, MV, Maganaris, CN. (2008). Human tendon behaviour and
adaptation, in vivo. Journal of Physiology. Vol. 586;71–81.
Pope, D, Goom, T. (2016). 046 Proximal Hamstring Tendinopathy with Tom Goom. Physio Edge Podcast. 4th May 2016