We’ve spent the last couple of weeks talking about the beginning stages of diagnosing hamstring tendinopathy and the guiding factors that determine exercise prescription. Now it’s time to get moving! While there is no established literature guiding the rehabilitation of proximal hamstring tendinopathy, Goom and his colleagues have some key points for clinicians to follow. “The key to management of all tendinopathies is progressive loading, performed within a pain-monitoring framework, to reduce pain and restore function. Rehabilitation should be directed across the kinetic chain and can be progressed to include energy storage and release to normalize load capacity in the entire lower limb.”
The authors have also outlined four consecutive stages of hamstring tendinopathy rehabilitation. Before starting these stages, remember to monitor pain throughout the entire rehabilitation process and let that guide your progression through the protocol.
Four stages of hamstring tendinopathy rehabilitation
This rehabilitation guideline is a marathon, not a race. “Progression through the stages described below is based on symptoms and response when progressing the exercise load rather than on specific time frames. The four-stage program is expected to take three to six months to complete, but is likely to show considerable individual variation depending on pain and functional deficits” (Goom et al. 2016)
Stage 1: Isometric Hamstring Load
Goom and colleagues (2016) start with resisted isometric exercise in positions without tendon compression to properly load the muscle-tendon unit and reduce pain:
- Exercise should be prescribed based on symptom severity and irritability.
- Keep the hip in a near neutral flexion/extension position or in minimal flexion for those just beginning rehabilitation.
- Exercises in this stage include:
- Isometric leg curl
- Bridge holds with hip in neutral
- Isometric straight-leg pull-down
- Trunk extensions
Courtesy of Goom et al. 2016.
Stage 2: Isotonic Hamstring Load With Minimal Hip Flexion
Stage two introduces isotonic load once the patient has minimal or no pain in stage one. Goom et al (2016) share that “the aim is to restore hamstring strength, bulk, and capacity in a functional range of motion, all of which are important aspects in rehabilitation of tendinopathy.”
- Heavy slow resistance training is paired with isotonic load exercises.
- This stage focuses on slow, fatiguing, resisted isotonic exercise, commencing at 15-repetition maximum and progressing to 8-repetition maximum, with three to four sets performed every other day.
- Loaded hip flexion should be reduced in early stages to protect the enthesis against compressive stimulus.
- Single-leg work is important to address asymmetrical strength loss.
- Exercises in this stage include:
Courtesy of Goom et al. 2016.
Stage 3: Isotonic Exercises in Increased Hip Flexion (70°-90°)
Stage three continues to construct hamstring muscle strength, hypertrophy and functional position training while in greater hip flexion. “This training can be commenced when there is minimal pain with higher-loading hip flexion tests” (Goom et al. 2016).
- Dosage and frequency of loading exercises are the same as stage two, every second day.
- Progressing to 70° to 80° of loaded hip flexion is generally sufficient, but this will depend on individual pain presentation and functional goals.
- Exercises in this stage include:
- Slow hip thrusts
- Forward step-ups
- Walking lunges
- Deadlifts
- Romanian deadlifts
Courtesy of Goom et al. 2016.
Stage 4: Energy Storage Loading
The final stage is reserved for those patients who are looking to return to sports that require lower-limb energy storage or impact loading. “Reintroduction of power/elastic stimulus for the myotendinous unit can be commenced when there is minimal pain and adequate bilateral strength in single-leg stage two and three exercises” (Goom et al. 2016).
- Early in stage four, the amount of hip flexion during exercise should be limited to minimize tendon compression.
- As this is the most provocative stage, a conservative approach is recommended, with exercises being performed every third day. For example:
- Day 1: Stage 4
- Day 2: Stage 1
- Day 3: Stage 2/3
- Day 4: Rest
- Exercises in this stage include:
- Sprinter leg curl with the TheraBand CLX
- A-skips
- Fast sled push or pull
- Alternate-leg split squats
- Bounding, as well as stair or hill bounding.
- Kettle bell swings
- Gradual reintroduction of sport-specific squat and lunge activities.
- For patients returning to multi-direction sports, include lateral, rotational or cutting movements to improve strength and control in multiple planes of motion.
- Sessions should contain a maximum of three to four of these exercises.
Courtesy of Goom et al. 2016.
Source: Goom T et al 2016. Proximal Hamstring Tendonopathy : Clinical Aspects of Assessment and Management. Journal of Orthopaedic & Sports Physical Therapy. 2016;46(6):483-493.
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