do you have a deep localized pain around your sit bone that often gets worse during or after activities like running squatting or sitting in this video I'm going to tell you everything you need to know about proximal hamstring tendinopathy including guidelines for how to best manage this condition your hamstring muscles attach to your ischial tuberosity also known as your sit bone and consists of three muscles the semi-membranosus semitendinosus and the long head of the biceps femoris they insert onto your lower leg and primarily contribute to knee flexion and hip extension similar to other tendinopathies proximal hamstring tendinopathy is characterized by persistent tendon pain and loss of function related to Mechanical loading this pain is located around the lower gluteal region which may remain not radiate down the back of the thigh and often occurs during activities and positions that place more stretch load and or compression through the proximal portion of the hamstring tendon examples include running uphill sprinting movements involving deeper hip flexion like squatting or lunging stretching and sitting for prolonged periods of time a sudden increase in some of these activities may be a contributing factor as to why you developed this condition in the first place a simplified explanation is that the load you placed on your hamstring tendon through different positions and movements may have exceeded your capacity to recover and adapt appropriately or in other words you may have done too much too soon this load is often associated with external factors such as the intensity volume and frequency of your trading for example did you recently incorporate uphill running or Sprint intervals into your sessions or have you been practicing yoga and including more stretching at the end range of hip flexion while tendon loading is a major component lifestyle and systemic factors may also play a role as these can reduce Your tendon's Capacity to tolerate certain loads for instance are you getting enough sleep how well do you manage your stress do you engage in regular physical activity addressing these factors during the rehab process is low hanging fruit that can have a significant impact on your overall health also it is worth noting that since hamstring Tenon pathology is common in people without pain Imaging is usually not necessary for this condition in terms of management not sir at all in 2021 found that injection therapies and surgery were believed to have limited utility this lines up with other tendinopathy research as they also have similar recommendations against these treatments in fact physiotherapy has been found to be as effective as surgery both in the midterm and long term for pain function range of motion and tendon force and pain treatment success and quality of life respectively therefore management will focus on two main components the first is load management and activity modifications which are about temporarily modifying and minimizing painful activities to Aid in long-term recovery this will help reduce the load side of the equation in order to allow you to continue running exercising sitting Etc with tolerable symptoms it is often a trial and error process but here are some suggestions if you have pain while sitting on Hard surfaces you can try sitting on a pillow or cushion another option is using a rolled up towel and placing it under your thighs in order to reduce the weight you place through your sit bone if it is the duration of sitting that is problematic you can take periodic standing breaks or get up and move around more frequently If you experience pain while running you may have to play around with your intensity volume and frequency as an example sprinting an uphill running will require more hamstring loading so reducing your speed and or running on flat surfaces can be Simple Solutions other considerations include modifications to your Technique over striding where your foot is contacting further out than necessary and running with a forward trunk lean can increase the load placed on your hamstrings therefore to address these you can try to increase your Cadence by five to ten percent or adopt a more upright trunk while running respectively if you still can't find a tolerable entry point after adjusting these variables you may need to hold off on running temporarily in order to allow symptoms to calm down in the meantime you could substitute it for other activities like biking swimming or an elliptical to help maintain Fitness levels if you have pain with squats lunges or other similar movements you could try to reduce the range of motion decrease the load or weight used perform them at a slower Tempo or substitute for another exercise that is more comfortable finally it is not uncommon for stretching to exacerbate symptoms if they feel good and don't significantly increase your pain it's probably okay to continue doing them but just know they are not necessary for recovery the second component of rehab will be performing exercises that emphasize Progressive hamstring loading these will help to further increase your capacity so you can eventually tolerate more load to date there are no clear guidelines for how to implement exercises for this condition however using the work from gum at all in 2016 not sir at all in 2021 and other tendinopathy research we can create a general rehab framework this revolves around the concept that pain has a dose-dependent relationship with the magnitude and rate of loading in other words a greater intensity and a faster speed of force will tend to increase the load on the hamstring which can lead to more severe symptoms for example a single leg RDL or a hip hinge is probably going to be more painful than a double leg RDL and sprinting is probably going to be more painful than jogging using this as a guideline rehab will follow a three-stage progression which gradually increases hamstring loading it will start with isometrics build up to heavy slow resistance through increasing amounts of hip range of motion and if necessary for your goals progress to jumping and plyometric exercises that prioritize a faster rate of loading before reviewing the exercises it is First Essential that you are able to appropriately Monitor and manage your pain similar to other tendinopathies it is unlikely that your rehab will be pain free as a matter of fact exercising into a tolerable level of pain has been found to be acceptable during this process this tolerable level is unique to each individual whether this means minimal or moderate pain is up to you but in any case here are three strategies to help monitor your symptoms one keep pain tolerable during exercise or activity the easiest way to do this is rate your pain on a scale from 0 to 10. what is the highest number acceptable for you whether this is a 3 out of 10 or a 5 out of 10 the decision is up to you two make a note of how you respond immediately after exercise or activity is the pain better worse or the same similar to other tendinopathies you may actually feel better after exercising due to what is called a warm-up phenomenon and three and arguably the most important assess how your symptoms feel the day after exercise if you feel better you might be able to make small progressions however if your symptoms are significantly worse this likely means you did too much the previous day and need to scale back let's look at how you can Implement these strategies using a self-assessment test first choose one of the following single leg exercises which are listed in order of difficulty based on hamstring loading Bridge long lever Bridge foot elevated Bridge long lever foot elevated Bridge or Romanian deadlift choose a variation that is within a tolerable level of pain if you can't find one you may perform any of these with two legs instead in this example let's say you choose a single leg foot elevated bridge on day one you perform one repetition and rate your pain as a two out of ten you then perform your rehab exercises later that day and feel good during and immediately after the next day you perform the single leg foot elevated Bridge again but now richer pain as a 7 out of 10. this means that even though you felt good during and after your rehab routine you may have done more than you can recover from this isn't necessarily bad but the next time you do your exercises it would be recommended that you scale back the volume or intensity this might be the number of repetitions or the weight you use at first it may be helpful to minimize exposure to multiple activities so you can gauge a more accurate response for instance if you perform your rehab exercises run and sit for a prolonged duration in one day and then the next day symptoms are worse it would be hard to determine what caused an increase in pain was it one exercise running or a combination of these activities you also don't have to use one of these exercises alternatively you can use one of your normal functional activities such as a daily morning walk as your self-assessment test stage one isometrics because these exercises involve little to no movement they are generally well tolerated and therefore often used as a starting point in most tendinopathy rehab protocols if you have more irritable symptoms these can be particularly helpful but I listed this stage as optional since not everyone will need to start with or include isometrics here are seven options in order of relative difficulty based on potential hamstring loading Bridge hamstring curl either prone or standing long lever Bridge foot elevated Bridge long lever foot elevated bridge and Roman Chair hip extension this means that the bridge exercise will theoretically be less demanding on your hamstrings while the Roman Chair hip extension will require your hamstrings to work harder therefore if you have increased symptoms starting with a bridge or a hamstring curl may be more tolerable if you want a more difficult exercise you can build up to the long lever foot elevated Bridge or Roman Chair hip extension you can do these exercises either with both legs or on a single leg the option you choose will be based on factors such as your tolerance symptoms function and access to equipment for programming pick one option and perform for three to five sets of 30 to 45 second holds at around a 7 out of 10 effort with a two minute rest between sets these exercises can be done independently up to three times a day or integrate it into your warm-up routine prior to your workouts stage two heavy slow resistance the goal of this stage is to gradually load the hamstrings and surrounding muscles through their full range of motion I will review five exercise categories including modifications and recommendations as appropriate there are no set criteria that you must meet before starting this stage rather you will have to experiment with the exercises to determine if they fall within the pain guidelines mentioned earlier for example can you perform a double leg Bridge or prone hamstring curl for repetitions without a significant increase in pain the next day you also might not be able to perform all five categories right away maybe you can tolerate Bridges knee flexion and hip abduction exercises early on but the hip hinge and squat movement might be too irritable these might be exercises you work up to over time category 1 hip extension with glute emphasis here's a four level Bridge progression level one double leg Bridge lift your hips up and squeeze your glutes before lowering back down once you can complete three sets of 15 repetitions with tolerable symptoms progress to the next level level two single leg Bridge aim for three sets of 15 reps on each side level three double leg hip thrust place your upper back on a bench or elevated surface so you can move through more hip range of motion aim for three sets of 15 repetitions and level 4 single leg hip thrust perform for three to four sets of 10 to 15 reps on each leg over time you can make this harder by adding weight Category 2 knee flexion option one prone hamstring curl if you have access to their equipment this could be a good entry point for loading the hamstrings since it requires minimal hip flexion start with the double leg variation and progress to a single leg once tolerated option 2 slider progression level 1 double leg eccentric start with your feet on sliders Bridge up and then slowly straighten your knees lower your hips down bring your feet back and repeat aim for three sets of 12 repetitions level two double leg slowly slide your feet out then use your hamstrings to pull them back in aim for three sets of 12 reps level 3 single leg eccentric aim for three sets of eight reps on each side and level four single leg perform for three to four sets of four to eight reps each option three Nordic hamstring curl set up in a tall kneeling position with your knees on a pad and your feet secured with your hips straight slowly lower to the floor or object in front of you catch yourself with your hands then push yourself back to the start finally option four is a seated hamstring curl since this exercise involves an increased amount of hip flexion and has a sitting component it is considered a more advanced option it might be an exercise you can work up to but is likely you will find one of the previous options more tolerable Category 3 hip extension with hamstring emphasis building up to a deadlift or Romanian deadlift will likely be the most challenging resistance exercise since it can place the most load through the hamstring tendon early on a more tolerable exercise might be a foot elevated long lever Bridge level one doubling Place both feet on a bench or elevated surface with knees bent about 10 to 20 degrees Bridge up until your hips are straight and then slowly lower back down aim for three sets of 15 reps level 2 eccentric Bridge up on two legs and while keeping the hips High remove one leg then slowly lower down repeat for three sets of 10 reps on one leg before switching sides and level three single leg keep one knee towards your chest and Bridge up and down through your full range of motion on a single leg perform for three to four sets of 6 to 12 reps on each side you can add weight over time if needed as symptoms allow progressing toward a hip hinge variation such as a deadlift can help build your tolerance to hamstring loading in a maximally stretched position here are a few options option one deadlift start with A reduced range of motion such as a kettlebell deadlift off an elevated surface as your symptoms improve gradually progress toward deadlifts from the floor if it fits your goal you can work through a similar progression using a barbell option two single leg deadlift start with body weight and work up toward holding a dumbbell or kettlebell if you struggle with balance you can use your hand for assistance option 3 Roman Chair progression level one double leg place your arms across your chest hinge forward then use your hamstrings to pull yourself back to the start build up to three sets of 15 repetitions through your full range of motion and level 2 single leg perform for three to four sets of six to twelve reps on each side to make this harder you can progress by holding a weight across your chest category 4 step ups and squats this category will introduce movements that involve deeper hip flexion ranges of motion similar to The Hip hinge you may find these irritable early on so ease into these exercises as tolerated here are two options Option One Step Up start at a low height if this is too difficult you can use your hands for assistance to make this harder gradually increase the height of the step and eventually you can add weight option two split squat progression level one heel is elevated squat elevating your heels will allow you to keep a more upright torso and perform the exercise with less hip flexion build up to three sets of 15 repetitions through your full range of motion level 2 split squat start in a split stance and slowly lower your back knee toward the ground keeping your torso upright if this is too hard you can shorten the range of motion or use your hands for assistance aim for three sets of 12 repetitions do your full range of motion on each leg and level 3 front foot elevated split squat place your front foot on an object two to four inches high and execute the same movement as in level two perform for three to four sets of 6 to 12 reps on each leg over time you can make this more challenging by adding weight Category 5 additional resistance exercises targeting the lateral hip and calf muscles can help address other possible deficits and help better prepare you for running in sport for muscles on the side of your hip there are several options some include short side planks regular side planks side steps with the band around your knees or ankles and hip abduction in standing with the cable or sideline with or without the use of a band or weight for the calves you can work through this standing progression start double leg progress to a single leg then a single leg deficit and finally add weight over time once you can tolerate stage two exercises you will perform them two to three times a week for example you can do Bridges prone hamstring curls and calf raises on Monday and the foot elevated long lever Bridge hamstring slider and hip abductions on Thursday as symptoms allow you can gradually introduce more advanced exercises like deadlifts squats and step UPS you can also continue to perform the isometrics as part of your warm-up and or on the other days of the week if you have the time and can tolerate them stage 3 energy storage and release if returning to running or Sports is one of your goals jumping and plyometric exercises that prioritize a faster rate of loading should be included some research suggests that you should have minimal to no pain during Advanced movements like a single leg RDL and comparable strength side to side during stage two exercises prior to starting this stage there are endless exercises to choose from but here are two options the first is a vertical jump progression start with a sub-maximal vertical jump on two legs where you build up to about eighty percent effort before progressing to a maximal vertical jump on two legs then work through the same progression but on a single leg make an effort to stick the landing on each jump perform for two to three sets of six to eight repetitions the second option is a horizontal jump progression which will require slightly more effort from the hip muscles on takeoff begin with a double leg sub maximal horizontal jump before moving on to a maximal horizontal jump after that repeat the same progression but on a single leg perform for two to three sets of six to eight repetitions once you meet the given criteria and if appropriate for your goals the easiest option is to program stage 3 exercises at the start of your workout for example you can do the vertical jumps on Monday and the horizontal jumps on Thursday before performing The Heavy slow resistance exercises when can you return back to running or your sport according to groom at all in 2016 a graded return to sport can be introduced when the athlete can tolerate the loading requirements of the sport with minimal symptom provocation each case will be unique but the main takeaway is that this process will be gradual and determined by your tolerance for instance if you are a recreational Runner who wants to run Hills or Sprint you would slowly build up the volume and intensity of your training over the course of several weeks to months if your goal is to play a team sport you would follow a similar process but would include sport specific drills before gradually returning back to practice and then eventually full competition for those who are less symptomatic you may actually be able to continue to compete in your sport by simply adjusting your training loads and incorporating the previously mentioned exercises during this phase you should still continue to perform the other exercises but you can program your runs practices and other activities into your weekly calendar based on your schedule goals symptoms Etc given that every situation is unique here are three case examples to help illustrate how the previous information can be applied for the first example let's say you are a 30 year old recreational Runner that experiences mild symptoms after recently introducing uphill running into your training tying in the first component of rehab you may find that you're able to continue running on a weekly basis as long as it is on flat ground and at slower speeds you also then introduce the progressive loading exercises twice a week in order to help build up your tolerance to hamstring loading you start with a heavy slow resistance exercises and then once you meet the given criteria you begin the jumping and Plyometrics after performing the exercises for a month or two you gradually reintroduce uphill running starting with less volume and or less intensity then as you continue to monitor your symptoms you slowly ramp up your effort over time in the next example let's say you are also a runner but you report progressively worse symptoms over the last six months and can no longer tolerate running even at reduced speeds volume and or frequency the best course of action would be to temporarily stop running and substitute it with a more tolerable form of aerobic exercise you could cycle use an elliptical or try a wide range of other activities there are a lot of possibilities so experiment with different options to find what works best for you you would then simultaneously incorporate the progressive loading exercises three times a week since you have more irritable symptoms you begin with the isometrics and then progress to the heavy slow resistance and plyometric exercises once tolerated after performing the exercises for several months you reintegrate the running back into your routine starting at slower speeds and less mileage as symptoms allow you gradually increase your intensity volume and frequency until you are back running at your pre-injury level or higher finally for the last example let's say you're middle aged and have been experiencing discomfort for the past two years this pain tends to intensify when you sit for extended periods and has impacted your ability to perform daily functional tasks first you would try to modify aggravating activities maybe it's sitting on a softer surface using a towel under your thigh and or implementing frequent standing breaks then to help improve your overall function you may choose to perform the isometrics and heavy slow resistance exercises a couple of times a week since you don't have any goals to run or play sports you choose not to include the plyometric exercises another consideration would be to gradually increase your general physical activity in order to address your overall health and well-being for example you could go on a five to ten minute walk every day and then slowly increase this duration over the following weeks to months the last thing I want to say before wrapping up this video is that this particular rehab will take time so you need to be patient follow the guidelines in this video and do not rush the process if you look at comments from our previous YouTube video on this topic you will see that people can struggle with symptoms for months to years you should set realistic expectations that recovery will take anywhere from three to six months or longer Unfortunately there is no quick fix additionally it is important to note that if you experience pain related to sitting this discomfort has been known to persist even after you have a full return to function as it typically takes a longer time to resolve in summary proximal hamstring tendinopathy is characterized by persistent tendon pain and loss of function related to Mechanical loading a simplified explanation for why this might have occurred is that the load you placed on your hamstring tendon through different positions and movements may have exceeded your capacity to recover and adapt appropriately or in other words you may have done too much too soon common examples include the sudden introduction of sprinting lunging or Hill running into your training or even excessive stretching into positions of deeper hip flexion to help facilitate recovery rehab will revolve around two main components first you will focus on load management and activity modifications which involves temporarily modifying or minimizing painful activities in order to Aid in long-term recovery second you will Implement Progressive loading exercises two to three days a week to help further increase your capacity so you can eventually tolerate more load throughout the rehab process it is vital that you Monitor and manage your symptoms is your pain tolerable during exercise is your pain better worse or the same after exercise and most importantly is you're paying better worse or the same the day after exercise using a self-assessment test like a single leg long lever Bridge or your daily walks can be a helpful tool in monitoring and managing your response to activity lastly you should set realistic expectations that recovery will take three months six months or even longer I can't stress enough the importance of being patient following the recommendations in this video and progressing with exercises and activities as tolerated thank you so much for watching if you enjoyed the video please hit that like button subscribe and even turn on notifications until next time