Proximal Hamstring Pain in Runners

By:  John Fiore, PT

The hamstring is an important and complex muscle group used in running. While minor hamstring pulls and strains are fairly common in runners, proximal hamstring overuse injuries can be very debilitating. Repetitive micro-trauma in the hamstring attachment site (ischial tuberosity of the pelvis) may result in proximal hamstring tendinopathy (acute tendinitis or chronic tendinosis). While proper diagnostic testing is key (clinical testing by an experienced physical therapist, real-time ultrasound by a sports physician), insufficient or incorrect treatment of proximal hamstring tendinosis can shut a runner down for months.  

Understanding the hamstring musculature is the first step.  Unlike most muscles in the human body, the hamstring crosses two joints (hip and knee) and plays a role in two distinct movements. The hamstring’s primary function is to flex or bend the knee. If your knee bends, you can thank your hamstring for its work. 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.  Understanding the hamstring is the first step in preventing and treating hamstring related running injuries.

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 a proper treatment progression is crucial. Strengthening the hamstring in a lengthened state (eccentric) versus a shortened state (concentric) will result in hamstrings which are strong 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. You can go to the gym five days a week and do hamstring curls to strengthen your hamstrings but continue to have pain while running. The key to effective treatment lies in understanding the hamstring’s role while running. A video running analysis is a helpful way to detect underlying running compensations and cadence which may influence running stride which increases hamstring stress.

A qualified physical therapist skilled at applying pain-relieving modalities, integrated dry needling, deep tissue release-mobilization, muscle energy techniques to balance pelvis symmetry, active release techniques, and contract-relax techniques will address pain and tissue restriction in the hamstring secondary to overuse. An eccentric hamstring strengthening program based on your pain, compensations, and goals will build tensile strength in your hamstring and tendinous attachments. Ruling out underlying pathology (such as lumbar spine referred pain) is important as well. Finally, do not forget to roll, release your hamstrings to decrease muscle and tendon tension. A few exercise examples are illustrated below, but see a qualified physical therapist to rule out underlying injuries,  referred pain, and for the gradual addition of strengthening exercises when appropriate. Call or email John, Holly, or Jesse at Sapphire PT with any questions or to schedule a consultation (406-549-5283 or john@sapphirept.com).

Proximal Hamstring and Core Exercises:

  1. Quadruped plank: May be modified by resting on your forearms. Do not allow your lumbar spine to extend or low back to sway-collapse.
  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.

  6. TRX hamstring curls: Lie on your back with heels hooked in TRX loops. Contract your glutes and raise your hips-pelvis off the ground. Slowly bend your knees and slowly return to a straight-knee position. Lower hips-pelvis to the floor and repeat.

Photo: www.strengthperformance.com

 

References:

  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.

 

Runner of the Month: December 2018

We have two new faces at Runner’s Edge and we’d like to take this opportunity to introduce them to you. Meet Sarah and Alex! Stop by and say hi if you get a chance.
Names: Alex Tait and Sarah Knutson
Hometowns:
AT- Jackson, WY
SK-Union, IL
How long have you been in Missoula?
AT- 6 years
SK-6 years
What is your favorite thing about Missoula?
AT- My favorite thing about Missoula is the community and the wondrous beer options.
SK-My favorite things about Missoula are the people and the access to trails.
What keeps you busy when you’re not working?
AT- Skiing and trail running. As well as moonlighting as a hitman for hire.
SK- I’m usually off running with my puppy or skiing at Discovery.
Do you prefer roads or trails?
AT- I prefer running on trails because no one can hear my screams of pain as I ask myself why I am doing this.
SK- I prefer running on trails because it’s more challenging and better for my soul than the roads. Running trails brings tears, joy, grit, and true connection to oneself.
What’s the funniest thing that’s happened to you while on a run?
AT- Slipped and fell in the mud and was totally covered in it. Saw a family hiking once I got near the trailhead and one of the little kids looked right at me and started crying.
SK- I once lost my footing and balance over a steep cliffside. While I was tumbling and sliding down I lost one of my shoes and still have a scar to prove it. Yes I can be pretty clumsy.
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Product Review: Darn Tough Socks

Amelia is one of our RE ambassadors for 2018/19. She is very active in the community and is one of the makers of the maps we all know and love, Cairn Cartography! We began carrying the popular brand, Darn Tough, and we wanted Amelia to share her thoughts on the wool socks made in Vermont. You can also follow her adventures on instagram @cairncarto, as well as on facebook.

Darn Tough Vertex ¼ Sock Review

The week before every big race I do, I find my way down to Runner’s Edge and pick out a brand new pair of socks to wear on race day. I usually buy something I’ve worn before so I’m not trying something new on race day, but having new socks to put on gets me excited to run hard and feels like a nice gift to my feet for all the hard work they have put in leading up to race day.

I started to write that I’m not particularly picky about which socks I choose for my race-day present, but I realized that’s not true. I am pretty particular about my socks. I like them to be wool, or mostly wool, I like short no-show socks unless it’s brushy or snowy and then I like some of my ankle covered. I like my socks pretty thin, and I really dislike toe socks. Finally, I try to buy all my gear from companies with a conscience. All that means I was pretty excited to review both the light and ultra light version of the Darn Tough Vertex ¼ socks this month!

My first impression when I took the socks out of their packaging was that they were really soft and super cute. The days of a pack of 10 all-white cotton crew socks are long gone, and it takes some good design for socks to stand out on the wall in today’s market. These come in cheerful color options that I really like.

Darn Tough is a family owned business based in Vermont, close the where I grew up, and they still make all their socks at their mill in Northfield, Vermont. They offer a lifetime guarantee, on socks, and pride themselves on products that are built to last.

I have a confession to make: I love the idea behind Darn Tough but until recently I really didn’t like Darn Tough socks. They use a higher percentage of nylon than other wool sock brands which makes their socks much more durable, but it also makes some of their thicker hiking socks feel really thick and unbreathable. For years I’ve gotten a pair of their heavy-weight hiking socks every year for Christmas, and every time I wear them my shoes feel too tight and my feet end up a sweaty clammy mess.

In the last few years I’ve started coming around, and after trying these ¼ socks I’m a big fan. I’ve spent a lot of time running with wet feet lately and the ¼ sock height is perfect for cold, muddy, slushy conditions, and even when my feet are soaked they feel warm and comfortable. Another issue I’ve had with Darn Tough socks in the past is the ankle feeling too tight, but these feel soft and comfortable without being so loose they fall down. I didn’t have any issues with bunching or falling down or slipping or any other problems with the way they fit. Mostly I forgot I was even wearing them until I went to take them off and realized my feet were much wetter than I realized, which is a good sign I think. I’ve been known to get holes in the toes of my socks after just a few wears but these, like all Darn Toughs are built to last.

I highly recommend you try these out if you are looking for some new socks to add to your drawer. Especially if you haven’t always loved Darn Tough socks in the past. Thanks for reading!

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Product Review: Cotopaxi Teca-Technical Windbreaker

Cory Soulliard is a Runner’s Edge Ambassador for the 2018/19 season. You can usually find him volunteering or running at almost all of our Runners Edge events! We asked him to review a jacket from a cool company, Cotopaxi, and his thoughts are below… You can follow his adventures with his pup on intagram @corysoulliard.

Fall is here. The mountains are dusted in snow, the mornings are frosty, and the views are amazing. It’s that great time of year when I want to be out on the trails as much as possible before they are covered in snow. A well timed run means I can still enjoy shorts and a t-shirt but heading back one of the the canyons in the bitterroot means I should not go without an extra layer. Do I take a layer for warmth? To stop the wind? To shelter me from the surprise
rain or snow? How about one that will take on all of those roles?

Quick notes:
Pros                                    Cons                                              Notes
– Light (4.6oz)                   – Pockets do not zipper                  – Bright, bold colors
– Packable                          – Elastic waist does not                  – Half-zip available
– Hood                                   cinch
– Collar protects neck
when zipped
– Vented back
– DWR finish
– Quiet

The Cotopaxi Teca jacket will only take up a little more space than a tennis ball and weighs a scant 4.6 oz so there are few reasons to bring it with you. I was able to shed the wind at the top of Trapper Peak and fend off a light rain around Lake Como while just wearing a light t-shirt underneath. Trapper was a classic fall trip that starts warm from the car but without some protection at the top there would be no way I could hang out and enjoy the view. My Teca jacket was basically nonexistent on the hike up but ready when I needed it at 10,157ft. The run around Lake Como started cool and damp so the jacket was in for a more thorough test.

The first thing I was noticing about the jacket was the noise. Many light jackets are more disruptive but I quickly realized that it was just the hood that I was hearing. The hood was not needed on this run so I tucked it in the collar and ran in almost silence. After a couple miles in 38 degree weather I started to heat up. There is an inch wide strip that runs the width of the back to ventilate while on the go and when I started overheating I just lowered the zipper a few inches to let some extra air in and ran on in comfort. Although the rain was minimal the DWR finish did keep me dry despite the efforts of all of the low hanging branches that were saving up their water for my passing. My legs and my socks did not remain so dry.

At 5’10” and roughly 140 lbs I decided on the men’s medium and I would say the fit is about right. The body is large enough I will be able to add a warm layer and wear this jacket through the winter but not so large that I feel like I am wearing a parachute. The sleeves are plenty long
so the elastic cuffs can actually meet my gloves. If needed the collar covers your neck when zipped up and the hood will wrap around your head to keep the heat in. My wife may have stolen the jacket for an early morning run and she approved of it. Although a size down would have been better fitting I get the impression that I might notice it missing again in the future.

Now I must be honest, I dress for function, not fashion. I would expect this Teca jacket to be worn by a stylish runner slipping through the crowds of NYC or on the cover of some running magazine instead of on minimally maintained trails. I don’t think I would have purchased the jacket because the 1990 style, bright, block coloring might be too bold for me. After wearing it a couple times I don’t feel as self-conscious as I expected. In fact on the dull grey days I think I like the addition of color to my world. As with all ultralight jackets I hope it can withstand the abuse on the trail. A recent run up Bear Creek Canyon did push the limits of the DWR as I was continually slapped with branches full of the previous night’s wet snow. Although I am not sure I stayed dry, I would say I was able to stay comfortable for the 2 hour adventure.

Anyone growing up in the late 80s-early 90s may feel right at home with the styling. Many companies tried their hand including The North Face seen here. If you miss the kangaroo pouch pocket be sure to check out the half-zip Teca. You will have plenty of room to bring along your sandwich, walkman, and a few slap bracelets for your friends.

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Winter Off Season Training: Gaining Fitness, Strength, and Durability

As snow begins to accumulate in the mountains surrounding Missoula, many runners long for the warm and sunny days we have become accustomed to over the past several months. Winter, however, provides a crucial opportunity to improve your overall health as a distance runner. Repeating the cycle of training-racing-recovering over several months takes a toll on the body. Consider complimenting your winter running with one of the many winter sports available to Montanans. Not only is winter cross training therapeutic, but it is fun as well. Introducing new movement patterns and loads will allow your bones, muscles and connective tissue to rebuild, providing long-term durability for the 2019 running season. Fitness is comprised of strength, mobility, aerobic conditioning, and power. While running is required to gain running fitness, it is important to gain strength, mobility, aerobic conditioning, and power to maximize running fitness. Winter is the time to train your weaknesses, not your strengths.

 

Strength training should be part of every off season plan for runners. A 2010 research article in the Journal of Orthopedic Sports Physical Therapy showed a correlation between impaired muscular control of the hip, pelvis, and trunk and increased knee pain in runners (Powers C. J Orthop Sports Phys Ther 2010;40(2):42-51. doi:10.2519/jospt.2010.3337). A strength training program aimed at providing functional stabilization of the hip and pelvis in multiple planes is, therefore, a vital part of any off season strengthening program. As we grow older, muscle strength becomes more important as we lose approximately 1% of our muscle mass every year. More importantly, the decline in muscle strength declines at a rate 3-times greater (Goodpaster, B.H., et al., The loss of skeletal muscle strength, mass, and quality in older adults: the health, aging and body composition study. The Journals of Gerontology Series A: Biological Sciences and Medical Sciences, 2006. 61(10): p. 1059-1064. https://www.ncbi.nlm.nih.gov/pubmed/17077199). Body weight strengthening is important if you are new to weight training or have a history of joint issues. To build muscle strength and durability, however, resistance training (bands, free weights, kettle bells) is necessary. Care should be taken to seek advice of a physical therapist or a personal trainer to assess your strength training technique. One muscle group many runners overlook are the calves (gastroc-soleus muscles). Between the ages of 20 and 60, runners typically experience a 31% reduction in ankle power, total power (ground reaction force to lift you off the ground and in a forward direction), along with a 13% decrease in stride length and running speed (DeVita P, Fellin RE, Seay JF. The relationship between age and running biomechanics. Med & Sci Sports & Exerc. 2016; 48 (1): 98-196.). Performing calf raises-drops and single leg hops will target the calves. Remember to slow down during weight training repetitions to maximize strengthening benefits. Two to three strength training sessions per week will compliment your winter outdoor activities.

 

Mobility becomes more elusive as we age. Runners are particularly vulnerable to stiffness in the knee, hip, and ankle joints as we move in only one plane. Addressing mobility restrictions with the help of a physical therapist will decrease your osteoarthritis risk and improve your running efficiency. Winter is the time to attend a yoga class, seek stretching advice, and have your running stride analyzed to decrease joint loading to promote joint health.

 

Aerobic conditioning requires consistent work. Experience has taught me that maintaining a base level of cardiovascular fitness in the offseason reduces the need to play “fitness catch-up” in preparation for spring running and racing. Building your aerobic engine to carry you up climbs both short and long requires specified training. High intensity intervals are never fun, but mixing it up the means by which you subject yourself to intervals reduces burn-out. Nordic skiing intervals, skinning (backcountry or ski mountaineering set-up) intervals, power hiking intervals, and cyclocross racing are great ways to disguise intervals in a fun and novel activity. One to two longer running or snow hiking workouts in your aerobic threshold range will build or maintain your aerobic fitness.

 

Photo courtesy of stretchcoach.com

Power is achieved through explosive movements such as plyometric exercises and through interval training. Short intervals included in a workout 1-2 times per week will provide the acceleration a summer of long miles has taken away. Utilize a watch timer and heart rate monitor to gauge effort. Plyometric exercises include a loading phase followed by a propulsive unloading phase. Plyometric exercises should not be done when sore or injured, and an adequate level of strength is necessary to perform correctly. Again, seek advice from a physical therapist or personal trainer prior to adding power training to your off season program.

 

Motivation becomes challenging as the daylight hours shrink and the temperatures drop. To avoid runner’s burnout, reduce your winter mileage and intensity and shift your focus on the exercise suggestions outlined above. Embrace the season and find an outside activity or sport which is intriguing. I discovered backcountry skiing and randonee or ski mountaineering two years ago. A January-March Thursday night race series (Rando Radness) at Montana Snowbowl which is organized by Mike Foote attracts skiers of all ages and abilities in a fun, social atmosphere. The winter days of riding my bike on a trainer indoors are long gone.

 

Durability will reduce injury risk by preparing your body for the demands of the running season. Overall fitness (strength, mobility, aerobic conditioning, power) combined with reasonable training volume increases and adequate recovery determine one’s long-term running durability. The off season is the time to build running durability as distance running and racing have a catabolic (breaks down tissue) effect on body tissues. Make the coming winter a season full of adventure, recovery, rebuilding, and fun.
John Fiore, PT

Runner of the Month: November 2018

Katy White moved to Missoula a few years ago and has quickly established herself as a fixture in the Missoula running community. She can be seen running anything from the Missoula Marathon, to the Rut, to the upcoming Turkey Day 8k. Recently she lead the Missoula women to a big win at Montana Cup in Great Falls.


How long have you been running? 

I’ve pretty much been running my whole life. Even as a little kid I would go with my neighbors to their middle school cross country meets and run all over the course even though I was in no way involved with the team. I started running competitively about ten years ago in high school when I sadly/luckily was the only person not to make the volleyball team and was forced to find a new fall sport. So I did cross country and track for the remainder of high school and continued on in college by being an active member of my schools club team. After graduating undergrad, the first thing I did each time I moved to a new place was to get plugged into the running scene as quickly as possible.


We’ve seen you run fast on roads, trails, and now cross country, what’s your preference?

I think I’m happiest with a little mix of everything. I love road running because you can go quicker and it’s fun to get the legs moving and into a rhythm. However, given where we live, I would be seriously missing out if I only stuck to the roads. I still haven’t quite mastered long climbs or steep, technical descents, but I love the variety and beauty that trails bring into my running. I also think mixing up the terrain is great for staying healthy and ensuring that all sorts of muscles are getting used regularly.


Now that you’ve found your stride in Missoula, what’s your favorite part of the running community?

I am really in love with the support and enthusiasm the entire community has for active, healthy lifestyles. Where I’m from in Indiana, my runs are done on busy streets with no sidewalks and to the soundtrack of drivers honking and yelling at me- not the most encouraging environment for fitness. In Missoula, regardless of the time of year or time of day, it is nearly guaranteed that I will cross paths with a handful of others out there and they are likely doing something even more extreme than I am. I think this breeds an incredibly motivating and encouraging environment regardless of your goals or physical endeavors.


You lead Missoula at Montana Cup. How did that race play out for you? Were you happy with it? 

I was thrilled with the outcome! I had heard that Missoula has a pretty dominant Montana Cup history, but the last two years that I have done the race we left empty handed on the men’s and women’s side. My only goal going into it was to do my best to help the women’s team come out with a win. During the race I was able to look back and could see that we were packed up really well in the front, which gave me a lot of confidence and encouraged me to push the last couple of K’s. I have been doing a lot of running in the South Hills, which I think was good training because I was able to get in a lot of hills that are still very runnable, just like the race course!


What do you have in mind for 2019? 

I just got confirmation that I got into the Chicago Marathon next fall, so I’m going to put a lot of effort getting ready for that and will hopefully come out with a big marathon PR! Throughout the next year I will be working on building up my mileage and incorporating a lot more speed and strength work into my running to help get ready for a solid Chicago buildup. I’m also definitely going to do a handful of other road and trail races like Snow Joke and the Bitterroot Runoff, maybe even one of the Rut races, because they are way too fun to miss out on!