Proximal Hamstring Pain in Runners: Effective Injury Treatment & Prevention Guidelines

Many Missoula runners have already toed the start line of a race or two by now. Training for summer races is in full swing, and now is the time to add intervals, speed work, and mileage. As running speed and intensity increase, however, hamstring overuse injury risk increases. The hamstring is an important and complex, two-joint (crosses both the hip and the knee joints) muscle group used in running. While hamstring pulls and strains are common in runners and often healed with rest, proximal hamstring overuse injuries can be very debilitating.  Repetitive micro-trauma in the hamstring attachment at the ischial tuberosity of the pelvis may result in tendinopathy (acute tendinitis or chronic tendinosis) and pain. While proper diagnostic testing is key (clinical testing by an experienced physical therapist or by a sports orthopedic physician), insufficient or improper treatment of proximal hamstring tendinosis can be a season-ending injury.

Understanding the hamstring musculature is the first step toward injury prevention. The two-joint hamstring plays a role in two distinct movements. The hamstring’s primary function is to flex or bend the knee. The hamstring’s secondary function is to aid in extending the hip.  Because the hamstring crosses both the hip joint and the knee joint, it is a key muscle in the running stride.

The hamstring is comprised of three muscles.  All three hamstring muscles originate on the ischial tuberosity of the pelvis. The semimembranosus and semitendinosus muscles attach on the medial side of the lower leg (tibia) below the knee.  The biceps femoris attaches on the lateral side of the lower leg (tibia) below the knee. The hamstring muscle group works in opposition to the quadriceps muscles.  When you are flying down a hill at full speed, quads pounding and quads burning, the hamstrings act as the “brakes” to prevent knee hyperextension and to initiate the push-off phase of running.

Once diagnosed with a series of clinical tests by your PT which place tension on the hamstring origin or attachment, establishing proper treatment is crucial. Reducing inflammation by reducing running mileage and stride length must occur first. Strengthening the hamstring in a lengthened state (eccentric) versus a shortened state (concentric) will result in hamstrings which are stronger and more prepared to check the power of the quadriceps while running. Core strength addressing lower abdominal, hip, gluteal, and lumbar strength in a functional manner will complement hamstring-specific strengthening to reduce overuse associated tissue micro-trauma.

Decreasing pain is only one component of a proximal hamstring injury prevention and treatment plan.  Strengthening the hamstring in a manner consistent with running is key in preventing injury recurrence. In order to quantify hamstring function, a 2D video running analysis is important to determine how you as an individual run. Are you using your gluteus maximus to extend your hip, or is the hamstring acting primarily? Are you over-striding and placing increased tension through your hamstring? A 2D video running analysis is a helpful way to detect additional underlying running compensations which may influence running biomechanics and resulting hamstring stress.

A physical therapist will customize plan to resolve your hamstring pain. Treatments may include:  pain-relieving modalities, integrated dry needling, active release techniques, muscle energy techniques to balance pelvis symmetry, myofascial release, and contract-relax techniques to address pain and tissue restriction in the hamstring secondary to overuse.  A cortisone injection may be indicated by your physician if proximal hamstring pain is inflammatory (tendinitis) in nature.  Finally, do not forget self-care such as adequate recovery, sleep, release, and eccentric hamstring exercises during the summer running season.  The exercises listed below are examples, but I recommend seeing a physical therapist to rule out underlying injuries or referred pain to enable you to resolve symptoms and reduce the risk of re-injury.

Call or email John with any questions or comments.

John Fiore
Sapphire Physical Therapy

Proximal Hamstring and Core Exercises:

1.  Quadruped plank: May be modified by resting on your forearms. Do not allow your lumbar spine to extend.

2.  Side lying glut isolation: Press into the wall with your heel and maintain a neutral pelvis position.

3. Quadruped hip extension: Contract the glut of your involved leg prior to extending your hip to decrease hamstring compensation.

4. Glut bridging: Contract your gluts (glut max) together and hold the contraction as you raise into a bridge position and hold for 5 seconds.  Slowly return to starting position and repeat for one minute. Further challenge yourself by repeating glut bridging exercise with the addition of single leg marching without allowing your pelvis to drop.

5. Eccentric hamstring-strengthening exercise using the treadmill: The treadmill is turned on to a slow speed, with the individual facing backward on the treadmill while holding on to the hand rails. The support side (the left leg shown) is placed off of the treadmill belt. The involved leg (the right leg shown) is extended at the hip while keeping the knee mostly extended, and the individual is instructed to resist the forward motion of the belt with the leg as the belt moves. The involved leg then is moved back to the starting point by flexing the knee and extending the hip.  Continue for one minute.

1. Cushman, D.; Rho, M., Conservative Treatment of Subacute Proximal Hamstring Tendinopathy Using Eccentric Exercises Performed With a Treadmill: A Case Report. Journal of Orthopaedic & Sports Physical Therapy 2015, 45 (7), 557-562.
2. Fredericson, M.; Moore, W.; Guillet, M.; Beaulieu, C., High hamstring tendinopathy in runners: Meeting the challenges of diagnosis, treatment, and rehabilitation. Physician and Sportsmedicine 2005, 33 (5), 32-43.

*Image from

Five Common Training Spring Training Errors to Avoid

Spring has arrived in Missoula and the roads and surrounding trails are filled with runners. Most runners have created a tenta
tive 2017 race schedule and motivation levels are high. Choosing the correct training plan, however, will likely determine your racing success over the next nine months. Whether you are participating in Run Wild Missoula’s Missoula Marathon Training Program, the Runner’s Edge Trail Running Class, utilize a running coach, or follow an online training plan, remember to avoid these five common training errors to increase your racing success.

1. Rapid Increase in Running Miles
A cold and snowy winter made winter running difficult in Missoula. A rapid increase in running mileage, however, is a fast track to developing a spring running injury. A 10% increase in weekly mileage is a tested rule of thumb to be followed. When mileage is increased too rapidly, fatigue sets in, running form is compromised, and injury risk increases. Log your running mileage and peel off from the group run if you are exceeding your 10% weekly running mileage.

2. Lack of Flexibility in Weekly Training Plan
Runners are inherently goal-oriented individuals. Therefore, successfully completing your weekly training schedule brings a sense of accomplishment. Experiencing an off day is a normal occurrence which should not be ignored. Fatigue, stress, poor sleep patterns, poor nutrition, and overtraining all contribute to having an off training day. If your body is not responding, modify your daily workout without guilt. If you missed a week of training due to prior commitments or illness, avoid the temptation to jump back in with the group. Allow room in your training plan for flexibility and your body will reward you with improved performance.

3. Ignoring Your Body’s Warning Signs
Most running injuries are related to overuse. Overuse, however, can be the result of overtraining, or a lack of strength necessary to run without compensations. If pain persists for more than 48 hours, seek medical attention which includes evaluating running biomechanics and determining the underlying cause of pain.

4. Running and Racing Injured
Although common sense tells us not run or race while injured, saying no is often the most difficult decision for a competitive runner. Race entry fees, travel plans, and sharing the race experience with friends and family are among the reasons many run and race injured. Rarely is the outcome positive and running or racing while injured only prolongs symptom resolution. A basic test is the 30-second hop test. If you can hop on a single (injured) leg without pain for 30-seconds, then initiating a return to running program is indicated. If you experience pain, then you are still injured and should rest, and work on strengthening any underlying weaknesses responsible for pain symptoms.

5. Neglecting Self Care 
Self care includes adequate sleep, proper nutrition, adequate rest days, rolling or massage, and strength training. Schedule self care into your weekly training plan. Contact Sapphire Physical Therapy for assistance in creating a strength training program and recovery routine to insure adequate stabilization and recovery necessary to run injury-free.
John Fiore, PT
Sapphire Physical Therapy

Picture taken from Google images

Winter Foot and Lower Leg Conditioning Exercises to Reduce Spring Injury Risk

February snow storms are sure to continue, despite our spring running training and racing goals. Winter activities such as cross country skiing, snowshoeing, and backcountry skiing are excellent ways to build strength and cardiovascular fitness, while providing a much-needed break from running. It is very important, however, to condition our feet and lower legs for the impact of spring running. Ski boots provide more support and rigidity compared to running shoes. Combine increased foot and ankle support with a low impact descent on skis, and the stage is set for spring running injuries.

Running places unique eccentric demands on the musculature of our feet and lower legs. During an eccentric contraction, a muscle contracts in a lengthened position to resist an opposing force. Greater demand is placed on muscle and connective tissue (tendons) during eccentric contractions. Running freely down a rocky mountain trail requires eccentric muscle strength. Now is the time to prepare your body for running with a few simple, targeted drills to make you more durable when the snow and ice melt.

1. Heel Raises-Drops: Increase the tensile strength of the Achilles tendon and calf musculature to reduce tendinitis and muscle strain. Picture1

2. Quick Feet Drills: Rapid, low impact footwork to boost agility and balance.Picture2

3. Plyo-Hops: Build power and shock absorption capacity with powerful bounding hops and cat-like soft landings.Picture3

4. Split Squats: Slow eccentric loading in a squat position followed by a burst and weight shift for leg and core strength.Picture4

5. Runner Lunge Hops: Stabilize-Hop- Stabilize-Repeat sums up the runner lunge hop. Try holding your position for 5 seconds when you land the hop portion of the runner lunge.

As with all strengthening exercises, slow, intentional movement with an emphasis on form and balance should be primary. Sufficient gluteal, core, and extremity strength is necessary before attempting an eccentric strength-based exercise program. Contact the running injury prevention experts at Sapphire Physical Therapy with your specific training or running injury questions.

John Fiore, PT
Sapphire Physical Therapy

*As a reminder, Sapphire PT will be at the Runners Edge Thursday, February 2nd & Thursday, February 16th from 5:15-6pm to answer any questions you may have on running-related injury issues.


How to Make 2017 an Injury-Free Year: Tips by PT John Fiore

Unlike New Years resolutions which dissolve over time, following a few simple rules will greatly increase your chances of running injury-free in 2017. Understanding why runners get injured, setting realistic running goals, listening to your body, and doing the work it takes to be a runner will result in a successful year.

Why Runners Get Injured

Sixty million people ran for exercise in 20151 Running is a simple, effective means of achieving fitness which is accessible for very little financial investment. Running injuries, however, can be frustrating and expensive to treat. Nearly 80% of runners sustain at least one overuse running injury per year.2 Other than the occasional trip, slip, or fall, the repetitive dynamic forces generated and sustained during running often result in lower extremity injury. Among the twenty common running injuries, 70% to 80% of these injuries occurring from the knee to the foot.3 The most common running injuries include patellar tendinitis, meniscus tears, iliotibial band syndrome, patella femoral pain, shin splints, plantar fasciitis, Achilles tendonitis, hamstring strain, stress fractures, and ankle sprain. The underlying cause of running injuries, however, is functional weakness of the hips and core which causes excessive motion in one or more planes of motion.

Three different planes of motion act on the hips and pelvis while running: Forward/backward motion (sagittal), side-to-side motion (frontal), and rotational motion (transverse). Stabilization of motion in these three planes through targeted strengthening exercises will allow you to run more efficiently while greatly reducing your risk of running-related overuse injuries. A bi-weekly strengthening program must include activation exercises (finding and feeling the muscle working), strengthening exercises (fatiguing the muscle), and dynamic functional exercises (working the muscle in positions which simulate the demands of running). In addition to the gluts, core, abdominals, and lower leg musculature, the upper body and trunk must be strong and mobile.

Weekly mileage increases must be incremental. The age-old 10% mileage increase per week rule is a safe and effective guideline. A gradual increase in your weekly mileage will allow for adequate recovery between runs, allow for muscle strength gains to be realized, and reduce connective tissue (tendons, ligaments, fascia) overload. Remember, rest days are as important as high mileage days. Allow your body to rest, sleep, recover, and be ready to go following your rest day(s).
Setting Realistic Running Goals

Motivation and mental fortitude is crucial to achieving training and racing goals. Physical training and a realistic understanding of your physical capacity will allow you to achieve success without injury. Seek the advice of training partners, experienced runners, and coaches to help set realistic racing goals. Once your 2017 running goals are established, create a training plan which includes terrain, elevation, distance, and temperature components similar to those expected in your upcoming races. Test your body and mind under these circumstances to confirm your fitness for your target race(s).
Listen to Your Body

Because each of the 60 million runners who ran in 2015 are unique individuals, flexibility must be built into our training routines. Listen to your body when you are tired (How’s my stress level? When was my last total rest day?). Listen to your body when you feel good (What did you eat yesterday? How many hours did you sleep last night?). Listen to your aches and pains (Where do I hurt? Does slowing down my pace help?) Does increasing my cadence help? When did I last strength train? Do I need to see a professional so I don’t get sidelined?). Running through exertional pain is very different than running through injury pain. Listen to your body and get advice to learn the difference.
Doing the Work

Running alone will not prevent running injuries. Less than ideal running biomechanics combined with repetitive motion associated with high mileage can stress muscle, connective tissue, and joints to the point of failure. Build up running durability through cross training, strength training, and adequate recovery. Have your running mechanics evaluated with a 2D video running analysis to document and visualize your biomechanics. Target your strength training to your individual needs rather than following a cookie-cutter program found online. Failure to do the work will greatly increase your risk of a running overuse injury.
Sapphire Physical Therapy is here to help you reach your 2017 running goals. Call us or email your questions and Happy New Year!

John Fiore, PT
Sapphire Physical Therapy


Mike Foote’s Testimonial on the Sapphire PT 2D Running Analysis

Two weeks ago I had the privilege of participating in Sapphire Physical Therapy’s new 2D Real Time Video Running Gait Analysis and I’m excited to share my experience.  Sapphire has been a major partner in the Montana running community for many years and they continue to show their commitment to keeping us healthy and running strong as the only PT clinic in the Northwest to have an on-site 2D Running Gait Analysis System.”
thumbnail_sapphire-p-t-running-analysis-32-Mike Foote, RE employee & The North Face ultra runner

What does a 2D Running Gait Analysis involve?
For all the amazing and detailed data you can collect from this analysis, the process is actually quite simple.  The Sapphire staff just asked that I wear running clothes for the appointment.  Upon arrival we discussed my running history and any current or chronic injuries I struggle with.  I then hopped on the treadmill and ran while the surface was flat for a couple of minutes and also on an incline for a couple more minutes.  Meanwhile they filmed me from two different angles with cameras which picked up on the LED lights they had taped to my body. These highlighted the actual angles of my joints as I ran in each phase of my running stride.   After finishing, we then watched the video together in slow motion. Frame by frame we were able to see objectively what occurs in my running form.

What I learned about my form:
I went into the analysis with no current injuries, though, I have struggled with tendonitis in my right achilles and left posterior tibialis tendons. Through this clear data we found that my hip drops slightly on my left side, which led to an asymmetry that stressed my lower leg.  We also found that my ankle dorsiflexes a little beyond the average angle. This too can cause unneeded stress on my lower legs and also cause me to be less efficient in my form. If this doesn’t lead directly to injury, it will indeed keep me from reaching the full potential of my competitive goals.  We then discussed certain exercises I can do to address these issues.

Take Aways:
Sapphire’s 2D Running Gait Analysis System is a fantastic tool in learning about what may be causing an injury or even exposing certain deficiencies which coulthumbnail_sapphire-p-t-running-analysis-16d lead to injury down the road. Though the amount of data produced in the analysis can feel overwhelming, the staff at Sapphire PT do a great job of breaking the information down into bite sized pieces for you to understand.  They also then highlight a few actionable things you can do to address deficiencies and strengthen certain areas.

Who can benefit from this running analysis?
This is for all runners who have either been injured, are struggling from an injury or would like to avoid injury.  Yep, that’s pretty much everyone!  So, if you would like to utilize this great tool to improve your running and ward off injury, I highly recommend you schedule an appointment with Sapphire PT today.  Check out their website explaining their Running Analysis and give them a call at 406-549-5283 to schedule an appointment.