Proximal Hamstring Tendinopathy (rehab)

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Hello all, I’m trying to learn how folks here have rehabbed and recovered from proximal hamstring tendinopathies.

I’ve been dealing with a proximal hamstring tendinopathy for about 6 months now. It started acting up in the spring in the middle of training for my 1st full distance triathlon. After lots of uncertainty about what is the pain driver (PT, massage, osteopath, primary care, …) I finally got an MRI. Diagnosis was a complex labral tear with proximal hamstring tendinopathy (PHT) as well as some tendinopathy in the glute medius/maximus.

After 3 additional months of PT and no running I got to see a hip surgeon (expert on labral tear repair). After thorough examination he is convinced the labral tear is not the pain driver and all my issue stem from the PHT. His suggestion was PT and slow return to sport. A platelet-rich plasma injection would also be an option, but his suggestion was to wait with it.

So my current plan is to stick with 4 weeks of total rest. Then proceed to PT for PHT and cross training (e.g. rock climbing) to get active again without the danger of aggravating the hamstring tendon in any way. After another 4 weeks of that I’m planning to bring in low-stress cardio (e.g. elliptical). And after another 4 weeks I’m planning to test the waters with some light running and biking.

It’s frustrating to deal with an injury that doesn’t really have a clear path to get it fixed. On the other hand, it’s probably a better place to be in that having the labral tear requiring surgery or ultimately needing a THR.

It would be great if others could share their dos and don’ts for recovery from a PHT. And if anybody got a platelet-rich plasma injection, I wonder if you think it helped.

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Yes, I overcame mine.

It started in mid 2021. After some fairly fruitless treatment (shockwave), I found an excellent physion (Stuart Butler, UK, Guildford) who prescribed the classic tendinopathy progression: isometrics, eccentrics, heavy slow loading. This was done via single leg glute bridges, with the affected leg elevated. See Foot Elevated Single Leg Glute Bridge - YouTube

We started off with 2 sets of 5x5s holds, then moved to 2 sets of 5x15s holds. When that was reasonably manageable, I moved to eccentrics (raise with 2 legs, then lower, over a full 10 seconds, with one). Then I added weight to that move, either by having a db on my lap or by having my wife push down on my hips on the eccentric.

The next stage was to do the full, single leg raise, with weight, with a 5s positive and negative.

This isn’t a recommendation, by the way - you’d need to see a physio for that - but it’s what I did which I believe is a very orthodox PHT rehab plan.

It was a process, sure but after around a month I saw real improvement, with more or less complete resolution after 3-4, through I understand that’s a bit quicker than average.

While rehabbing it, I was told it’s fine to keep riding, but to really minimise hills, aero positions, and hard efforts. I pottered round on the hoods in z2 - or stuck to the trainer (riding mainly on the tops at z2 and tempo), which was a godsend for me.

The final suggestion I’d consider is a bike fit. I have to run my seat height 10-20mm lower than most orthodox bike fitters recommend, but I’m a heel dropper, and that gets worse if I go hard up hills.

I still get the odd day when i wake up and it’s a little sore, but a week of daily isometrics always sorts it.

This is fixable, but you need to have a plan and be consistent. Good luck.

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This is almost always a bad idea, btw. Tendons need loading to remodel. Resting will take away the pain but as soon as you return to activity, it will (usually) recur.

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Thank you for the perspective. Very much appreciated. It’s great to hear stories of success in the sea of drawn-out horror stories. The PT plan you followed is very well aligned with what I worked out with my PT–so good validation there as well.

I totally hear you on the bike fit. Both my bikes (road/gravel and tri) are pro-fitted. But one piece of intel I got from a shop manager is that a lot of PHT is caused by long hours on a trainer. For one, people don’t move or even shift their weight. So hamstring tendons are continuously irritated without any relief. In addition, many tend to shift their weight backwards on the saddle during hard intervals to generate more power which further grinds the tendons between sitbone and saddle.

As for the rest, I don’t see it is curative for the underlying problem. I just want the irritation and inflammation to die down a but so I get a better feel for how far I can push during the recovery rehab and return to exercise.

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