Understanding and Overcoming Hamstring Tendinopathy: A Guide for Runners in Washington DC

As a runner, dealing with pain is part of the journey—but when it lingers, it can disrupt your training and progress. If you're experiencing discomfort deep in the back of your buttocks, especially when running uphill, sitting for long periods, or increasing your running intensity, you may be dealing with hamstring tendinopathy. This is a condition we frequently treat at our clinic in Washington, DC. It can be challenging to manage, but here are some of our best guidelines.

What Is Hamstring Tendinopathy?

Hamstring tendinopathy occurs when the tendon, which connects the hamstring muscle to your pelvic bone, becomes overloaded. In running, your hamstring tendons transmit forces anywhere from 3 to 9 times your body weight, especially during intense efforts like speed work or hill running. The pain typically arises when the load exceeds what the tendon can handle. This is common after a period of inactivity followed by a quick return to running, or when there's a sudden increase in training volume or intensity.

Other factors, like age, sex, and individual strength levels, also play a role in the development of tendon issues.

Why Does It Hurt So Much?

Hamstring tendons are sensitive to compressive forces—think prolonged sitting, deep hip flexion, or running up hills. When the tendon is compressed and stressed beyond its tolerance, it becomes irritated. Over the next few weeks, minimizing activities that involve prolonged sitting or deep hip flexion will be crucial to reducing pain.

The Good News: Tendons Adapt

While tendinopathy can be frustrating, the good news is that tendons are adaptable. With the right combination of exercises, we can gradually increase the tendon’s tolerance to high loads. Tendons get stronger when properly loaded, and that's the key to recovery.

During your assessment, we identified a few underlying issues contributing to your discomfort, including limited hip and lumbar spine mobility, decreased hamstring and glute strength, and poor tolerance to hamstring loading. We’ll address these through a combination of manual therapy, mobility drills, and a structured loading program designed to get you back to pain-free running.

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Pain During Rehab: What’s Safe?

It’s important to understand that mild pain during rehab is normal and safe. Think of it like pressing on a bruise—it might feel sore, but you're not doing any damage. However, if you notice higher pain levels or increased stiffness the next morning, it's often a sign that we've progressed too quickly. In these cases, we'll simply adjust the exercise intensity or volume to help manage your symptoms.

Load Tolerance Test: Know When You’re Ready to Run

As your recovery progresses, it’s crucial to ensure your body is prepared to handle the impact of running. Simple load tolerance tests can help gauge your readiness. I recommend using three key exercises: single-leg bridges, single-leg squats, and single-leg Romanian deadlifts (RDLs) to assess your hamstring tendon strength and comfort.

The goal is for you to complete 3 sets of 10 reps of each exercise with good form and minimal discomfort. If, during any of these exercises, your pain exceeds 3/10, consider it a red light—this means your body isn't ready for the demands of running yet, and we should hold off on returning to full training.

Begin with the bridge and march, as it places the least stress on the hamstring. Once you're comfortable with this exercise, progress to the Long Lever Bridge, which offers a moderate challenge to the hamstring tendon.

When you can perform the Long Lever Bridge without pain, move on to the Single Leg Romanian Deadlift (RDL). If the Single Leg RDL feels too aggressive, try the Kickstand version instead. In this modification, limit your hip hinge to a pain-free depth to maintain comfort while still engaging your hamstring effectively.


Recovery Progression Plan

Here’s what the next steps in your rehab journey will look like:

  1. Initial Strength & Stability
    We’ll start by focusing on pain-free movement and coordination with single-leg bridge variations. Once you can do these without pain, we’ll move on.

  2. Advanced Strength & Range of Motion
    Next, we’ll introduce exercises like Romanian Deadlifts (RDLs) and lunges. These help strengthen your hamstrings and increase tolerance to the ranges of motion needed for running.

  3. Plyometric Phase
    Once you’ve built a solid foundation, we’ll progress to plyometrics, including jumping and hopping. These exercises help the muscle-tendon unit regain its ability to handle the powerful forces involved in running.

  4. Return-to-Run Phase
    We’ll start a run/walk program designed to gradually build your running volume, with a goal of reaching 30-45 minutes of continuous running in about four weeks.

  5. Return to Training Phase
    Finally, we’ll increase your training frequency and reintroduce different types of workouts like long runs, intervals, and speed work. The aim is to get you back to running 5+ days a week at various intensities.

Importance of Patience and Gradual Progression

Recovery from tendinopathy takes time, and it’s important to stay patient and trust the process. Tendons heal differently than muscles—they respond slower but become stronger with consistent, gradual loading. Progress may feel slow, but it’s important not to rush, as pushing too hard can risk a setback.

Managing Flare-ups

It’s common to experience minor flare-ups during recovery, especially if you increase your activity too quickly. If this happens, don’t panic. Instead, scale back your activity, focus on low-impact exercises like walking or cycling, and resume more intense activities once symptoms improve. This approach helps keep your recovery on track while reducing pain and inflammation.

Cross-Training

While you’re managing your hamstring tendinopathy, maintaining your overall fitness is essential. Low-impact cardiovascular exercises such as swimming, cycling, or using the elliptical are great alternatives to running while you're building up tolerance in your hamstrings. Cross-training not only helps maintain your aerobic fitness but also ensures that your return to running is smoother when your tendon is ready.

Preventing Future Tendinopathy

After recovering from hamstring tendinopathy, preventing future injuries is key. Building strong hamstrings and glutes, improving mobility in the hips and lower back, and avoiding sudden increases in training volume or intensity are all critical. Incorporating a regular strength training program focused on the posterior chain (hamstrings, glutes, and lower back) can help reduce the risk of future injury and improve your running performance long-term.

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Don’t let hamstring tendon pain slow you down. Contact us today to schedule a consultation!