high hamstring tendinopathy vs. Piriformis syndrome: please disguish

I've been doing yet more research on this issue and came across this excellent blog post. If the author reads here, i'd like to know how he is doing.

http://www.running-physio.com/my-pht/

I've struggling with this same injury for the past 5 years. I first felt the pain on a fartlek run during a base building training period. The pain was so bad, I could not run and driving for an extended period of time led to excruciating pain. My solution was to take six weeks off from running and perform a lot of stretching and targeted massage (i.e. probing the area to feel the pain and sitting on a tennis ball, etc.) When I started back running, the pain was down to a dull throb that was manageable and seemed to decrease once I warmed up. I found that sudden speed increases would aggravate it, so I spent a lot of time running slow and steady. I managed to get back to marathon training levels (60-75mpw for me) and was doing will until I aggravated it during another fartlek run that was probably too soon after a marathon. I found that low intensity hamstring curls seem to help, so I do a lot of 1-leg hamstring curls at low weight - took a little experimenting to find the right starting point, too much weight and you immediately feel the ping indicating a problem. But, the added strength seems to help and I am currently back on full speed training. Although I am still very fearful of sudden pace increases, so I try to gradually ramp up speed in workouts, jogging into intervals and moderately accelerating up to speed. So, if you haven't tried it, I'd recommend 1) rest until the pain subsides to a manageable level, 2) stretch and massage the area, and 3) "light" weight work.

thanks ache,

i'm several months into it now.

i've got a strength routine that includes one legged deadlifts, eccentric ham curls, one legged sled presses, one legged squats, and lots of stretching.

i didn't stretch at first and even stretching now irritates the upper hams but now it doesn't make it worse.

I've had some improvements where i can run and have even done some 200s and 400s which in fact feel pretty better than running slow. but over increasing distances, that dull ache returns. i wonder if it is because i've got an increased range of motion from the stretching but the strength isn't there yet?

So, my plan now is to start running on the treadmill at a really high grade. it doesn't hurt it but it tires the hams out really quickly. maybe this will strengthen it??

my conclusion is that unlike some injuries where people say "I had ART, deep tissue, did x exercise, etc... and it was fine it in a week"...this is something that will take a very long time to knock out.

Keep us up to date with how you're progressing...or not.

deadlegged wrote:

I've been doing yet more research on this issue and came across this excellent blog post. If the author reads here, i'd like to know how he is doing.

http://www.running-physio.com/my-pht/

This blog suggests that hill running might be bad for your hamstring. (And I had thought hill sprint was safer than sprint on the track...)

Anyway, I went to a PT (who is a runner), and she immediately spotted my imbalance that I had suspected for a long time. A few things that might have caused this imbalance are: crossing my legs while sitting and carrying heavy weight always on my right side.

Ya, I saw that and was hesitant to try any uphills at all. But the blog only talks about this as being bad in the reactive stage. I'm long past this stage. Hill sprints are still "grabby" but the slow uphill running didn't hurt it.

I've been at a desk for 20 years. This past june, i got a stand up desk. I can now stand on a binder and stretch my calves and put my knee on a chair and stretch my hip flexors. I'm less stiff at the end of the day.

The reality is that i've had some hamstring issues for 13+ years. But the whole roof caved in when i tried to train for a marathon last year.

I really think this is a really slow process of healing tissue that has been trashed for a very long time. I didn't get this overnight and i think it's a long haul before i'm doing tempo runs again.

But i'm thrilled with the progress i've made in the past 12 weeks.

I changed my strategy in the past week or so. I'm able to run but after about 30 minutes, i get the dull achiness in the upper hams. My PT routine that includes stretching with a rope ala Wharton, one legged dead lifts, straight legged cable pulls, ham curls, and one legged sled pressed got me to this point.

But i can't get the proximal hams to heal. I'm going to do what Afredson did when he came up with the idea of the eccentric heel drops for achilles tendinopathy. Do so many eccentrics that i either tear the tendon or heal it.

http://www.walkerstreetsportspodiatry.com.au/#

!Origins-of-the-Alfredson-eccentric-heel-drop-protocol-for-achilles-tendon-pain-Its-a-good-story-I-promise/cszh/1

according to the research, from

http://www.runningwritings.com/2013/11/achilles-tendonitis-in-runners.html

"The reason why the eccentric exercise program boasts such impressive results is linked to how it affects tendon structure. Ultrasound imaging and MRIs of tendons before and after the eccentric exercise program show a reduction in abnormalities, a reduction in tendon thickening, and a return to normal tendon structure.40, 46 Exactly how this is accomplished is not yet clear, but J.D. Rees et al. propose that eccentric loading puts unique stresses on the tendon not found in concentric loading which encourage tendon healing."

The hard part here is that there are studies saying that eccentrics are key for proximal hamstring tendinopathy but there is no nice, neat randomized trial like the Afredson protocol to state which exercise and how much to do. So, i picked those 3 to

The exercises:

1. Nordic drops - 2 sets doing them till i can't do them anymore 2x per day

2. Using the physioball: lift up with both legs, roll out with one leg, put butt back on floor. 1 set of 15 on each side (cause that's all i can do right now)

3. Using physioball: lift up with both legs into a bridge, bring butt back down to floor with one leg. 1 set of 15 on each side

this last one seems to engage the upper ham the most which could either be really good or really bad.

In addition, i am doing NOTHING that that irritates the upper hamstring tendons...no more deep squatting, one legged dead lifts, or straight leg cable stuff, and no more digging into the area with a ball. no more uphill treadmill running (bad idea!)

Day one of being complete OCD about these was this past wed. I'll report back on progress.

For the past 13 days, i've been doing the following 3 exercises 2 x per day and i think i'm onto something.

1)Bridge lowering on ball - Same position as this guy but lower with just one leg.

https://www.youtube.com/watch?v=LfhMGrKegO4

2)Ball rollouts -

Just what is shows here

https://www.youtube.com/watch?v=AS9eqB_hZqo

3) Nordic hamstring exercise -

https://www.youtube.com/watch?v=IbmuE4clhg4

I started out doing:

Nordics - 1 x 20, 1 x 10 morning and night

Ball lowering - 1 x 15 morning and night (1 each side)

Ball rollouts - 1 x 15 morning and night (1 each side)

After a week, my shoulders, wrists, and elbows started getting too sore so this past week i cut the nordics down to 1 x 20 once per day.

I think the ball lowering exercise is the most effective for replicating the feeling of the eccentric calf exercises. It pulls on the tight proximal tendon in the correct spot without 'pinching' it so i wanted to increase the reps on this.

But ball exercises are really intenses on the calves and ankles and i found that i couldn't do more than 15.

So i added a set of these using a chair instead of a ball and it does the job.

Things are improving. I was walking around the other day and realized that i didn't feel my ham when i put my heel to the ground walking. My runs the past few days are getting smoother, the ache after 30 mins is more dull, and i'm going a bit faster without the effort.

i won't declare victory yet. but i'm sticking with the plan for another few weeks before happily reducing this routine to once a day.

I've had sore, tight proximal ham tendons for 10+ years and this is the most progress i've made in the shortest amount of time in all these years of experimenting with stuff to cure this thing.

Follow up to the thread.

I have now completed 11 weeks of what i've dubbed the "extreme eccentric" program for high hamstring tendinopathy. However, i made some modifications starting around 7 weeks in. Previously, i had been doing 3 sets x 15 2x per day of:

straight leg ball rollouts, ball or chair bridges, and unilateral one legged dead lifts. I had also been doing the nordic hamstring exercise.

I made lots of improvement but then it leveled off. My upper hams were sore all of the time so i stopped anything that pulled directly on the upper hams which meant dropping the unilateral dead lifts and the nordic hamstring exercise. I also went to doing the others to once per day versus twice.

But where i subtracted exercises, i added in the myrtal/donkey kick routine daily. At the end of week 8, i was making progress again. My stride became more loose and my pace picked up but i still have tightness and some pain after around 30 minutes. I also really get sore doing any fast segments. But it dawned on me that the pain is now more directly in the piriformis/glute area. The main area of pain is what you feel when you do a side lunge.

So starting in week 9, i began doing triangle pose and reverse triangle along with "Whartons quick tip for piriformis syndrome" stretch and lots of clamshells, reverse clamshells, and other mini band work.

In addition, i went back to the RT article on high hamstring tendinopathy and have been doing all of those exercises every other day and cut back on eccentrics to just every other day. i've been able to add back the unilateral deadlifts but just barely bending over. I still avoid directly pulling on the upper tendons but they are not nearly as sensitive now.

every other day at the end of my runs i do slides, crossover, skips, butt kicks, and jumping lunges along with some one legged hops. I just started adding in kettlebell swings

Improvement comes in spurts and it's very, very subtle. I'll start a run and i will be like "this is the day that the stiffness won't happen". Inevitably it does but it's getting slightly better all the time.

I'll report back in another 4 weeks. The biggest lesson is that tendons take a very, very long time to heal. But the Noakes Law of running says "there are very few running injuries that are permanent" or something like that. I am still pursuing healing this like the law is correct.

What's the name of the article? I can't find it form the link (unless I'm just dense, which post my morning marathon is possible)

@deadlegged

Just wanted to ask how things worked out? Still having hamstring issues? Do you think your regimen would have been more effective with less/no running?

Wow! 3 years later.

apologize in advance for the length of this post.

I had limited success with my eccentric program. What i finally did was go to a chiropractor whose niche is running injuries. His take on these types of injuries is that due to tightness or weakness, the muscles that are supposed to be doing the work, mainly the glutes, stop doing the work so other muscles take up the slack. after doing this for several years "you run out of guns".

the stuff he had me do seemed really weird and not anything like the PT stuff i had been doing. each month i went back and he gave me some different ones. over the course of around 6 months, i was running well enough where i was able to hurt my achilles. This is what knocked me down for most of last year but i still had some lingering ham/butt pain. I went back to the guy last october and he had me doing something very similar to what is describe in this article that came out in RW at the beginning of the year. This was the last piece of the puzzle

http://www.runnersworld.com/stretching/how-to-correct-your-posture/slide/1

after diligently doing the one where you lay on your back and breathe out hard every day for a few weeks, i'm now running pain free. But i got pretty heavy into cycling the past couple of years and now i'm not sure if i want to go back and train for running anymore. It feel crazy good to be able to run without and freaking pain. It's seriously been like 15-20 years where my hams have felt this good.

In short, i don't think you can strengthen and stretch your way out of this. I wish i had gone to this guy sooner but i'm kind of into science and research and the "muscles not firing" stuff just didn't jive with that.

Please consider reading Travell and Simons work on pain and trigger points. The groin pubic pain could be in your adductors.

Those breathing exercises don't seem to be enough to cure piriformis syndrome. I'm assuming correcting posture along with the other stuff you were doing helped solve your issue.

I hear ya...I hear ya....WHAT IS THIS CRAP ? Running...are you kidding me ?....I have enough problems just walking or sitting. Pain in butt, pain in hip, tightness in leg & pain in my left heel. This stuff is driving me crazy! I’m no runner at all & never have been. 1st Dr says you have Piriformis Syndrome so they do dry-needling into my piriformis muscle 3x week for 3 weeks then PT. 2nd Dr says oh no, that’s rare especially in men...gotta be something else...PT for another 5 weeks. Last Dr says, I think it’s your s.i. Joint ...gave injections in s.i. Joint. Nothing is fixing this pain so far. I came across a video online about “ high hamstring tendonitis” today so just started doing those exercises to see if it helps. This all started with a pain & slight burning sensation where my left butt cheek meets my upper leg, then as time went on my hip, butt, leg, & heel started hurting nonstop. When I sit the pain immediately intensifies and my leg starts going numb. I’ve even had shooting pains in my groins sometimes.

Any help would be appreciated !!

skeptically wrote:

Those breathing exercises don't seem to be enough to cure piriformis syndrome. I'm assuming correcting posture along with the other stuff you were doing helped solve your issue.

Yes. those exercises were the last piece of the puzzle. but they made a difference. i had a really stiff upper back which must have contributed to this problem.

This is all behind me now. i have no hamstring pain. part of the reason i may have actually healed it was that i just started biking, a lot. the ham stopped getting stretched out at all for a good 2-3 years. but i never gave up on trying to fix it. here are the things that i think were the most valuable:

1. Glute activation exercises. Examples: stand with offending leg bent at 90 degrees the lift the heel to the butt. lay on stomach and put big ball between your feet, bend knees to 90 degrees and lift the ball up and down;. one legged bridges with the opposite leg either straight out or hugging it into your chest

2. strengthen the adductors and abductors: adductors, squats holding a pilates ring or ball between your knees; and abductors using a mini band

3. not sure if it worked or not but found that when i started doing the exercises using the slant board (an old cabinet door on a step) with the ski pole (a metal pipe from our scrap pile) that they could have helped. in addition, one legged calf raises.

4. mot importantly, i think that avoiding stretching or strengthening in the location of the pain. in hindsight, one legged dead lifts, the hamstring on the big ball exercises, and any stretching were not helpful and likely made it worse. it's injured! why in heck i thought it was a good idea to work it more shows a lack of any judgement! it needs to heal

i kind of think that it's a really complex injury and that it's not just a weakness. it seems as if there are many things that play into why this is such a frustrating injury and it takes someone who has the skill and ability to help you figure it out.

good luck. i really feel your pain.