Do you get that stubborn pain at the top of your hamstring right where it connects to your “sit bone” and you are wondering if it is ok to run with hamstring pain? This could be a dull achy pain that gets worse after your runs or sitting for a long period of time during your work day. Do you dread long car rides? Like so many of you, I have suffered from proximal hamstring tendinopathy (PHT) when I started running and thought to myself…will it ever go away?
I have helped several runners overcome this stubborn chronic condition that is literally a pain in the butt and wanted to share the best tips and hamstring injury exercises that I have learned over my 17 year career as a physical therapist and running coach. Everyone responds slightly differently but the strategies I will outline in this article will set you up for success in utilizing the most evidence informed treatment we have on this somewhat mythical condition. If you are a frustrated runner who has already been to physical therapy that included no running, heat, ice, massage and hamstring stretching and you are considering injections or surgery, please keep reading, listening, and watching the tons of valuable content in this resource. As you will soon find out, the best way to get you back to running and get rid of this butt pain forever looks much different than what you have been told and experienced in the past. Here is a teaser…you don’t have tight hamstrings…and if you do it is not the reason why you have hamstring pain!
In episodes 23 and 24 of the Healthy Runner Podcast and in this article, SPARK Physical Therapy wanted to help you as a runner become stronger with specific tips on how to deal with hamstring pain. In this article, we will take a deep dive and discuss what hamstring tendonitis (or butt pain) is in runners. We will share treatment as well as the best exercises for your hamstrings to help your body be more resilient with your running and to prevent any future hamstring injuries!
During episode 23, I was fortunate enough to be a guest on the Strength Running Podcast podcast with Jason Fitzgerald to share my knowledge on hamstring tendon pain.
Click the audio file above to listen to our conversation in which we got down to the root cause of hamstring injuries, how to strengthen your hamstrings, prevention advice, as well as dispel some common myths about rehabbing hamstring injuries.
Click the video below to watch the LIVE training I did on this topic within the Healthy Runner Facebook Group
The hamstrings are a group of muscles on the back of the leg. The hamstrings include the biceps femoris, semimembranosus, and semitendinosus. These muscles work together to bend the knee and extend the hip. The hamstrings are powerful muscles and can become very tight and cause pain when being used consistently. The hamstrings originate at the ischial tuberosity, which is a bony landmark on the back of the pelvic bone. In a more general explanation, the hamstrings start high up on the thigh, or in the middle of our butt cheek. They run along the back of our thigh and insert on the tibia and fibula.
Hamstring tendonitis occurs due to overuse and/or inflammation of the hamstring tendon. The inflammation can cause damage to the tissue in the form of microtears, which is what causes the pain. There is also the possibility that the hamstring will pull on the origin site at the bone, therefore causing pain in the upper thigh.
Click the audio file below to hear my detailed explanation of hamstring pain and how to overcome this condition in EPISODE 24 of the Healthy Runner Podcast
The symptoms associated with hamstring tendonitis can either be proximal, near the upper thigh, or distal with pain closer to the knee.
The most common symptom is pain or burning higher up in the butt or down lower at the knee. There can also be swelling in the back part of the knee as well. Generally, with hamstring tendonitis, the pain will get worse with repetitive exercise and with putting pressure on it (sitting during your work day after you go for a run). Perhaps the pain will go away when you’re resting, but in the middle of your long run you start to feel the pain. The pain can either be sharp, achy, or a burning sensation.
OVERUSE, OVERUSE, OVERUSE. Hamstring Tendonitis is an overuse injury! This happens due to the hamstring experiences continuous load and tension on it through activity. When you’re running (especially the long runs), every time you push off and land your hamstring is absorbing some of the force. Running requires repetitive bending of the knee and extension of the hip, meaning the hamstrings are also constantly being forced to contract and relax to move those joints.
The pain that patients with this pathology experience comes from the strain on the muscle that begins to put tension on the hamstring tendon. Depending on the location, there will either be strain on the proximal tendon in our sit bones or pain in the distal tendon at the knee. The tension put on these tendons from overuse is what causes the pain.
The important point to note is that it is tendon that gets irritated. Usually these problems are due to overloading of the tendon. The tendon hasn’t been stressed correctly during your training and it doesn’t have the resilience to tolerate the running you’re doing. This usually occurs at that proximal hamstring tendon site and we refer to it as a proximal hamstring tendinopathy (PHT) or tendinosis. This is not your common tendonitis where it’s an inflamed tendon but more of a degenerative condition that if left untreated with continued symptoms for years of running will eventually lead to a hamstring tendon tear. Before you go and seek out an orthopedic surgeon to either get an injection or surgery, please read these actionable tips that is a compilation on how we treat tendons differently than we did 20 years ago!
Treatment of this injury is going to depend on the severity of the injury and how long you have had this pain.
Most of the runners I see with this condition have already tried hamstring stretching and it does not help. The reason is because it is not that your hamstring muscle length is restricted or you have tight hamstrings, the root cause of the problem is usually a weakness issue and a lack of ability for your hamstring tendon to withstand load and the demands of running.
Below, I will outline the general treatment plan that has helped hundreds of runners get back running doing what they love without that stubborn pain in the butt. Keep in mind this is a generalized plan that will help 75% of you reading this if you do in fact have hamstring tendinopathy. However, there is no substitute for a personalized evaluation to get properly diagnosed and working 1-on-1 with a medical professional who has a ton of experience treating runners with this condition to help guide you on timing and specific prescription of when to implement these treatments. Overall, if I had to share 1 golden nugget tip that will give you the most bang for your buck in overcoming this condition it is to start loading the tendon with strengthening to make sure your hamstrings are strong! This will be pivotal in preventing hamstring tendonitis and helping you get back to running as healthy as you can!
This will help release and loosen up the soft tissue. In general we see hamstring dominance in the actual hamstring muscle meaning the muscle is contracting and firing too much so the gluteus maximus is not doing as much work, causing the hamstrings to feel “tight”. Foam rolling is a great self treatment technique that you can do on your own that will help to desensitize this area and loosen up the tissue. To learn more about soft tissue care for runners (my 4th tip to healthy running) click this Link from a previous blog post I did on this topic.
Click the YouTube video below to learn how to foam roll your hamstring properly by isolating either the outside muscle or the 2 inside muscles. This video actually shows my top 5 foam roller exercises for runners but the second exercise in this video is amazing for the hamstring! This is important to do to help loosen up tissue and increase mobility in the muscle.
At SPARK Physical Therapy, I like to compliment self foam rolling techniques with instrument assisted soft tissue massage (IASTM). You may be a runner who can benefit from seeing a massage therapist who can “work out” that hamstring muscle. To learn more about IASTM, click this video on my YouTube channel.
The other soft tissue treatment option that can be beneficial for treating the hamstring pain in runners is trigger point dry needling. Dry needling is a skilled intervention that uses a thin filiform needle to penetrate the skin and stimulate underlying myofascial trigger points, muscular, and connective tissues for the management of neuromusculoskeletal pain and movement impairments. To learn if dry needling is the same as accupuncture click the video below to find out. If you are wondering what dry needling looks like and how it is performed for the calf muscle especially if you have tight calves or chronic achilles pain, plantar fasciitis, and shin splints.
Notice how I did not say “stretch your hamstrings” before a run? That is because we know better nowadays and what your dad did back in the day does not help today! In order to get our muscles ready for running we need to prime the muscles with movement based exercises as opposed to trying to hold and stretch our muscles. In this video, I explain why you should be stretching dynamically and then I demonstrate and share my favorite hamstring specific exercises that I include in the program of the runners I work with as part of their movement prep before running or hitting the gym.
If you are a creature of habit and you must statically stretch your hamstrings, please do it AFTER your run! Click THIS LINK to watch a simple video I created during my run to show you how to stretch your hamstrings if you get back pain.
Glute activation is essential for running to provide proper propulsion forward to decrease the stress to the hamstrings, knee and ankle soft tissue structures. Research supports including exercises that target your glutes for treatment and prevention of common running injuries such as hamstring, patellar, and achilles tendinopathy. Glute inactivation (or sleepy glutes) can come from either muscle weakness or poor running form.
Here is how to use your glutes with every step you take during your running:
🔹 Head looking straight forward
🔹 Shoulders back
🔹 Slight bend at the hips and NOT the trunk
🔹 Drive through the hips activating the glute to propel yourself forward
Many of the runners I work with have dominant hamstrings meaning they are overusing the hamstrings instead of using the bigger more powerful muscle…the Gluteus Maximus!
This is especially apparent with hill running as your glutes are the prime muscle to power you up that hill and sometimes the top part of the hamstring becomes the prime mover trying to extend your hip and get you up that hill. The hamstrings need more help and that is where some good old fashioned glute isolation exercises can be very helpful. I know you may be saying to yourself, but I am already doing squats, deadlifts, and lunges in the gym…doesn’t that mean I have strong glutes?
I have seen many runners who are doing they great compound movements using mainly their quads as well as their hamstrings. Check out the video series below that I start my runners with to teach their body how to use their glutes! This is a first step prior to advancing to more complex and running specific exercises. These exercises are great for activating the glutes before a run!
For a great progression once your glutes are turned on…give this explosive lunge exercise a try to focus on what we call triple extension (at the ankle, knee, and hip joints). Really push down into your heel and then drive through activating that glute in a nice run specific manner!
I can not emphasize this enough that the best thing you can do for your hamstring muscle to load it to facilitate healing with strengthening exercises. Eccentric exercises are fantastic for strengthening muscles and specifically helping tendons heal. An eccentric exercise is when the muscle is lengthened under tension. These types of exercises are good for increasing the force production of a muscle and loading the tendon to allow for remolding and healing. In fact, these are the KEY to getting over stubborn chronic hamstring tendon pain! Trust me, I have been there personally and I have seen these work for hundreds of runners I help.
CAUTION! You need to make sure that you do not have pain greater than a 3/10 (on a 1-10 pain scale) when performing these. Also, please be sure to start with lower reps (6-8 reps) for 1-2 sets and then building up eventually to 3 sets of 10 reps. These require more force production from both your muscle and your tendon and you can easily do too much too soon or suffer from delayed onset muscle soreness (DOMS)
I have 5 great eccentric hamstring exercises to help you stay strong!
Do you want to know more about our SPARK Physical Therapy running injury clinic to help you with your hamstring pain or learn more about our healthy runner evaluation to get you on a specific plan to PREVENT any running related injuries so you can continue hitting the pavement doing what you love?
Here is what it looks like when I help you overcome hamstring tendinopathy virtually and what you will feel only after a couple of sessions!
Thank you (running friends) for taking the time to read and I hope you enjoy the podcast episode!
Stay active, stay healthy, and just keep running!
Duane Scotti, PT, DPT, PhD, OCS
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“I went to see Duane early into my marathon training with hamstring pain. At that time, I was barely able to run 3 miles and was in pain. After a thorough exam and analysis of my running, he was able to diagnose and start treatment that day. Duane provided me with exercises to strengthen my hamstring and surrounding running muscles, all while slowly building my mileage back up. He was honest with me about setting realistic goals for my race and helped me to meet those goals. With his help, I was able to run the New York City Marathon.”
“I first went to Duane prior to training for my first full marathon because I had some aches and pains from running that I wanted to sort out. Duane was able to diagnose the problems immediately and I went home pain free. The exercises he prescribed were personalized to my needs and within a few weeks, I felt stronger and pain free while running so I could get to healthy training! It’s great to have a physical therapist who understands athletes and encourages people to continue to stay active. I highly recommend Duane to any person who is looking to stay healthy while maintaining an active lifestyle!”
SPARK Physical Therapy was instrumental in my recovery of from achilles tendinitis. I visited a podiatrist who said I would need surgery to shave down a bone spur and Haglund’s Deformity. The recovery would be at least 8 weeks and at the time I was 24 weeks from running the NYC Marathon. Duane evaluated me and said I needed to work on my calf muscle and flexibility. We started treatment with dry needling and specific exercises that I could do on my own. The pain subsided and even after some long runs everything was starting to feel better. I will tell you that I ran and finished the NYC Marathon without pain or issues from my achilles. Had I not met Duane about a week after my podiatrist appointment I would have needed to defer my marathon and probably would still be recovering from the surgery. I was able to run through my injury safely and achieve my goal. The refreshing thing about SPARK Physical Therapy is they do not push for ton of session. I met my running goals in 10 sessions spread out over 3-4 months. Big Thank you to Duane and I highly recommend seeing him for any running injury you may have!
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