Management of Proximal Hamstring Tendinopathy – A Case Report

Management of Proximal Hamstring Tendinopathy – A Case Report

Hi! I'm Dr. Sara Solomon. Welcome to my website! For decades of my life, I had severe pain in my right knee, right proximal hamstring and left low back, a sequela of muscle deficiencies and imbalances. Trying to learn the splits on a faulty foundation made my symptoms WORSE. You can learn a lot from everything I went through. The way I fixed it is unlike anything you will find on the internet for management of high hamstring tendinopathy: I was my own guinea pig: I experimented on myself and came up with a unique way to overcome the cause of my symptoms by amalgamating physiotherapy and StrongFit principles. That's how my "Learn the Splits Program" was born.

I realize that some of you may experience high hamstring pain (especially if you are a runner or do yoga). If so, then read my case report! You'll quickly learn why I do lumbopelvic stabilization exercises every day!

p.s. it took me 8 weeks to write this one! Heads up: It's a formal Case Study... so it's a fancy schmancy writing style. 😃


Title:

A case report of proximal hamstring tendinopathy which responded to progressive hamstring, gluteal and VMO strengthening, lumbopelvic (core) stabilization exercises, extracorporeal shockwave therapy, and spontaneous emotional release.


Author:

Dr. Sara Solomon, BSc Physical Therapy, DMD, Certified StrongFit Coach, CF-L1

sara@drsarasolomon.com, http://DrSaraSolomon.com

creator of the Strength Academy and the Splits Program

Written in December 2018


Abstract:

Study Design: Case Report

Introduction: Proximal hamstring tendinopathy (PHT) typically presents as deep, localized buttock pain in the region of the ischial tuberosity that often worsens with running, sitting, and static stretches that involve sustained end-range hip flexion. There are no randomized controlled trials investigating rehabilitation of PHT, and there is a paucity of literature on the physical therapy management of PHT other than recommendations to increase hamstring strength and flexibility. The management outline presented in this case report aims to guide StrongFit coaches and future research.

Case Presentation: A 40 year-old retired female dentist with a history of chronic left low back pain presented with right-sided buttock pain and tenderness to palpation at the ischial tuberosity, a consequence of overzealousness with learning the splits. Her symptoms were exacerbated by sitting and end-range hip flexion and extension. Upon examination, it became apparent that her right PHT and left low back pain were both a sequela of decreased left lumbopelvic (core) stabilization.

Management and Outcomes: The symptoms of the right PHT improved significantly over the course of 6 weeks with lumbopelvic (core) stabilization exercises, progressive hamstring and gluteal strengthening,  VMO strengthening, dry needling, and extracorporeal shockwave therapy. After 6 weeks, the client was able to sit, touch her toes and perform the splits without pain. This case report also provided supportive evidence that spontaneous emotional release may help restore physiological balance of the nervous system. In order to heal, both the physical and emotional components of the low back pain were addressed for the client. Further research is needed to determine the effectiveness of these interventions for this condition.

Keywords: proximal hamstring tendinopathy, emotional release, StrongFit, splits


Introduction (Background):

Proximal hamstring tendinopathy is an insertional tendinopathy that typically presents as deep, localized buttock pain in the region of the ischial tuberosity that often worsens with running, sitting, and static stretches that involve sustained end-range hip flexion (e.g. splits).

PHT is an uncommon overuse injury typically seen in long-distance runners. It is most likely related to repetitive microtrauma from muscle imbalances and improper training.⁹ Contributing factors may include compression or shearing forces²  of the tendon at its attachment. The hamstrings have a common attachment on the lateral aspect of the ischial tuberosity: the semitendinosus and biceps femoris (long head) share a conjoined tendon, whereas the semimembranosus origin is deeper¹¹.  The semimembranosus is the most commonly affected hamstring muscle in proximal hamstring tendinopathy.³ Chronic tendinopathy with dense fibrosis can entrap components of the sciatic nerve, causing radicular-type neuropathic pain in the involved extremity.⁴

Risk factors include imbalances, core weakness⁵, previous injuries⁶ (for example, strength can be reduced from a previous knee injury), weak and tight hamstrings, anterior pelvic tilt (this increases stress at the hamstring origin), poor lumbopelvic (core) stability⁷, leg length discrepancy, other kinetic chain deficits (i.e. gluteus maximus atrophy, gluteus medius weakness) as well as excessive, repetitive overloads and over training.

Historically, treatment has focused on soft-tissue mobilization (e.g. transverse friction), stretching, progressive hamstring and gluteal strengthening, lumbopelvic (core) stabilization exercises, dry needling and extracorporeal shockwave therapy. Most athletes make a full recovery within 3 months of diagnosis.¹º

Note: lumbopelvic (core) stabilization refers to muscular activity in the trunk and pelvis that maintains the spine and pelvis in a neutral alignment.

This is an interesting case report because it also takes into consideration the emotional implications of chronic pain and injury. It is theorized that there is a strong correlation between the physical and emotional aspects of disease, and that suppressed emotions may indeed be inhibiting structural releases and healing.

This case report provides supportive evidence that chronic pain and injuries may have both a physical and emotional component. In order to heal, both the physical and emotional components need to be addressed and released.

By combining traditional treatments with emotional release techniques, the client’s symptoms significantly improved over the course of 6 weeks.


Case Presentation:

History:

This case involves a 40 year old ambidextrous female who presented in November of 2018 with deep localized pain in the region of the right ischial tuberosity.

The client is a retired dentist and professional fitness bikini model who enjoys pole fitness, bodybuilding, and StrongFit training. She is also a certified StrongFit Coach with a degree in Physical Therapy. She practiced dentistry full-time for 12 years  in the 11 o’clock position: this caused her to lean her torso to the left and elevate her left shoulder to gain visibility to the oral cavity. Although her job confines her to a desk many hours a day, it also requires a lot of physical activity (she is an online fitness influencer). The client lost her father to cancer in October 2017, but otherwise reports that she is happy and content in her life. She has no history of depression, and tends to be more “anxiety-driven”.

Chief Complaint: “I have chronic pain in the right proximal hamstring, buttock, and region of the ischial tuberosity preventing me from doing right front splits. I also have chronic left low back pain”.

The PHT symptoms first became noticeable in the Spring of 2017. Symptoms were felt in the right proximal hamstring, buttock and ischial tuberosity during end range hip extension (during hip thrusts and sandbag carries) and end-range hip flexion (during the inner hamstring opener). At this time, the right knee was also excruciatingly painful, so the right proximal hamstring symptoms were put on the back burner.

In September of 2018, the symptoms dramatically worsened during a session of “splits transitions” for pole fitness. It is worth noting that the client had only recently learned how to do the splits at 40 years of age, and that she is a “very intense person” who likes to learn and achieve at a fast pace. She initially managed the acute symptoms with ice, massage, ultrasound, and Tylenol, and she abstained from the right front splits. The client reported a worsening of the symptoms with prolonged sitting, end range right hip extension, right front splits, and end-range right hip flexion. The client reported no change in her pain levels with traditionally-based therapy (rest, ice, massage, ultrasound). In fact, she started to notice occasional episodic radicular-type neuropathic pain in the involved extremity.

The client also reported a 2-decade history of chronic left low back pain/spasm which  was exacerbated by external torque chain exercises. She has a 2-decade history of severe right knee pain which mostly resolved after 14 months of StrongFit training. Her left upper trap dominance dramatically improved after a year of StrongFit training.


Goals:

  • Instant goal: decrease pain in the right proximal hamstring, gluteus maximus, and ischial tuberosity, as well as the left low back.
  • Mid-term goal: increase active hip extension and flexion (without pain)
  • End-vision goal: pain-free passive and active splits. Complete resolution of symptoms in the left low back.

Assessment:

Ideally, an MRI is required to confirm the diagnosis. An MRI can detect tendon thickening, tearing, and inflammation at the ischial tuberosity⁸.

Eye Test: Stance:

Mild hip shift to the right

Overhead Plate Test: Left latissimus dorsi smaller

Increased lumbar lordosis and anterior pelvic tilt. This increases tension in the hamstrings and causes a lengthened position of the origin and insertion. This altered pelvic position also decreases hamstring strength.

Eye Test: Bending over

Hypertrophied left mid back compared to the right side

Eye Test: Squat bottom position:

Right gluteus maximus slightly smaller than left (weaker hinge on the right)

Right foot slightly externally rotated (weaker glute max, inner hamstring, and VMO on the right)

Left leg: mild inward collapse (weaker gluteus medius on the left)

Single Limb Stance:

Slowly lift 1 leg 3-4 inches off the floor and see if the client can maintain a level pelvis

She cannot stabilize her pelvis when she stands on her right leg and quickly loses balance. A compensated Trendelenburg occured: the trunk leans ipsilaterally to the side of the stance leg. During gait, however, an uncompensated Trendelenburg was observed (contralateral pelvic drop).

Leg Length:

Leg Length Discrepancy test revealed symmetric leg lengths.

Bent-knee stretch test: Positive for the right leg.

In the supine position, the hip and knee are maximally flexed. Slowly the knee is straightened by someone else or you can use a rope and do it on yourself (the hip must remain in 90° of flexion). The test is positive if there is pain in the ischial tuberosity.⁸

The Puranen-Orava Test: Positive for the right leg.

This is a standing test. Place one leg on a bench/plinth so that it’s in 90° of hip flexion with the knee fully extended. Reach towards the toes. The test is positive if there is pain in the ischial tuberosity.⁸  

Slump test: Negative.  

The purpose of the test was to assess for any irritability in the nervous system along the path of the sciatic nerve. This test was performed because the client reported a few instances of radicular-type neuropathic pain.

Palpation:

Exquisite tenderness over the right ischial tuberosity.

External Oblique Opener:

Less engagement of the left external oblique and lower abdominis compared to right side

Cannot fully extend at both hips while maintaining a posterior pelvic tilt (knees have a soft bend)

Seated Straight Leg Raise:

Struggles to stabilize the spine and pelvis when actively flexing the left hip.

Less hip flexion active range of motion (AROM) on the left compared to the right (despite pain in the right ischial tuberosity). The left side is weaker.

Staggered Stance Inner Hamstring Opener:

Compared to the left side, there is less mobility of the right inner hamstring (limited by pain in the proximal inner hamstring and ischial tuberosity)

Right foot slightly externally rotated foot (weaker right glute max, inner hamstring, VMO)

Pain in the right gluteus maximus at end-range lockout.

Struggles to stabilize with right vastus medialis oblique (VMO)

Compensates with the left mid-back.

Single Leg Glute Bridge:

Pain at end range hip extension in the region of the right ischial tuberosity.

Air Squat Test:

Less weight bearing through the right leg. She struggles to fire the right VMO. Client has a fear of using the right VMO because of her 2-decade history of knee pain.

Sandbag Squat Test:

80 lb sandbag: after 15 reps, the left glute med gives out and the left leg collapses inward and the low back starts to hurt. There is less weight-bearing through the right leg and the right VMO isn’t firing.

Pistol Squat Test:

Left Pistol: Can easily perform a left pistol squat in internal torque, barefoot.

Right Pistol: Unable to stabilize in the bottom position on the right leg. Difficulty getting back up: defaults to outer quads and external torque chain muscles, or else falls over. Relies on shoes (lifters) to cheat mobility.

4-Pack Opener:

Struggles to activate the left 4-pack (upper rectus abdominis), latissimus dorsi and gluteus medius.

Jefferson Opener:

Decreased activation of the left gluteus medius (unable to achieve a vertical shin on the left side).

Sumo Deadlift Isometric Activation:

Struggles to fire left upper 4-pack, left latissimus dorsi and gluteus medius

Pain in the left low back

Hip Shift to the right (weaker left gluteus medius and core)

Front Splits

Decreased hip extension causes her to compensate by overloading the front leg hamstring. She exhibits this pattern for both the right and left leg splits, but it is more pronounced for the right leg splits. Note the lack of hip extension in the rear leg in the photo below.


Interpretation of Findings:

  • Right Side: Decreased strength gluteus maximus and inner hamstring (weaker hinge pattern). Difficulty firing the right VMO. This right-sided lower extremity weakness is contributing to the spinal shift and associated left low back symptoms.
  • Left Side: Decreased ability to activate the 4-pack, gluteus medius, and latissimus dorsi (weaker squat pattern). Defaults to left mid and low back muscles.
  • Left Side: weaker external obliques, lower abdominis, transversus abdominis, 4- pack, and psoas. Defaults to the left mid and low back muscles. Hip musculature tightens to compensate (this decreases hip mobility).
  • AROM: decreased hip extension R > L (right side limited by pain), decreased hip flexion L > R ( right side limited by pain, left side limited by weakness)
  • Lacks lumbopelvic stabilization: the left external obliques, lower abdominis and transversus abdominis are weaker. This contributes to the symptoms in the left low back. It also causes the hip flexors and extensors to compensate by “tightening up” to provide the body with stability (since the core isn’t doing it’s job). Forcing “locked up hips” that lack adequate hip extension into the splits will cause front loading of the hamstring on the front leg. This exacerbates shear forces at the hamstring tendon insertion at the ischial tuberosity.

Diagnosis:

Right proximal hamstring tendinopathy, a sequela of decreased lumbopelvic (core) stabilization, a weaker right hinge (gluteus maximus/inner hamstring), a left gluteus medius deficiency, right VMO deficiency, decreased active hip extension and overzealousness with the splits.

The left-sided core deficiency contributes to the left low back symptoms and it was most likely caused by the deleterious postures adopted during the practice of dentistry.

The left low back symptoms could also have a possible emotional component (possibly a sequela of repressed emotions over of the loss of a loved one).


Treatment:

The treatment plan addressed both the physiological causes of the symptoms, as well as the emotional components that were possibly aggravating the symptoms.

The immediate goal was to decrease pain in the right proximal hamstring and left low back. During the initial reactive phase of healing, the client was advised to avoid end-ranges of motion that irritated the injury (i.e. end range hip flexion and extension). Compressive activities like steady-state running and jump rope did not elicit symptoms and were not contraindicated.

Since prolonged sitting aggravated symptoms, a chair cushion was used to reduce compression by allowing for more weight bearing on the posterior thigh instead of the ischium.

Note that anti-inflammatory medication was not prescribed in this case because the client has allergic anaphylaxis reported for ibuprofen, ASA and COX-2 inhibitors.

Over a 6 week period, 2 sessions of dry needling and 6 sessions of extracorporeal shockwave therapy were performed once a week by a physical therapist. The client also self-treated the affected area with ultrasound during the first 2 weeks. Limited evidence is available on the effectiveness of dry needling in the treatment of proximal hamstring tendinopathy⁹ and further research is needed into the efficacy of extracorporeal shockwave therapy.

Note: Trigger point dry needling involved the application of a fine filiform needle into the hamstrings to treat muscle and tendon dysfunction. It is speculated that it decreases pain and improves myofascial mobility, allowing for decreased tension on the proximal tendon at the ischial tuberosity.⁹


Exercise Program:

The client was advised to prioritize feeling the correct muscles over the rep scheme, and to re-adjust (i.e. scale the range of motion, decrease the weight, reposition herself) in the event of any compensation patterns or symptoms. She was advised to stop the set if she was unable to perform it asymptomatically.

Exercises were performed barefoot (if feasible) to tap into prioriception. i.e. “corkscrew inward” for internal torque (IT) exercises and “corkscrew outward” for external torque (ET) exercises.


Lumbopelvic (core) stabilization exercises

Lumbopelvic (core) stabilization exercises were performed daily over the 6 week period, and the client is continuing to perform these exercises going forward. The client also signed up for weekly Pilates classes. After 1 week of performing these exercises, the client noticed marked improvement in her left low back pain. She also noted increased pain-free active hip flexion and extension on the right side.

The client performed 3 sets to failure. The goal was to perform these exercises without any compensatory motion (i.e. to ensure the correct muscles were being recruited). 

  • ET: 4-pack opener (feet against wall to tap into lateral foot proprioception)
  • IT: External Oblique Opener with pelvic floor activation
  • IT: Transversus abdominis (TA) muscle activation exercises: supine unilateral alternating heel lifts/hip flexion/heel slides
  • IT: Practice standing on one leg (right and left) without the hips shifting. The client was advised to practice standing on the weaker right leg during activities of daily living. Progress to standing hip hikes.
  • IT: Bird Dog, both sides (on the floor, on a yoga block, on a Pilates ball)
  • IT: Wall Bridges with alternating toe taps
  • IT: Front Planks
  • IT: Side Planks (right and left)
  • IT: Copenhagen Planks (right and left)
  • IT: Foam Roller (or Pilates ball) Alternating Heel Slides, Hip Flexion (with and without a resistance band, using the low abs) and Straight Leg Raises (right and left, using the low abs). This exercise was initially scaled by performing it on the floor.
  • IT: Banded Rotational Lunges (Resisted Wood Chops in a Lunge)


Progressive Hamstring and Gluteal Strengthening¹³

Progressive hamstring and gluteal loading was the key to managing the proximal hamstring tendinopathy (to increase tissue load capacity). Progression was based on the symptoms, rather than on specific time frames.

Stage 1: Isometric hamstring/gluteal loading. This stage was initiated during week 1. The client was instructed to shorten/lessen the contractions based on the symptoms.

  • IT: Bridge holds bilaterally, progressing to unilaterally. Unilateral exercises are performed on both sides. The guideline was 5 sets of 45 second holds,¹² but the client was advised to prioritize feeling the correct muscles over the duration of the isometric hold.

Stage 2: Isotonic (eccentric and concentric) hamstring/gluteal loading. During this stage, hip flexion was kept to a minimum. This stage was initiated in week 2 because the client’s symptoms had improved. These exercises were performed every other day (unless symptoms worsened). The isometric exercises were performed on the “off” days. Unilateral training was prioritized to address imbalances in strength. Note: unilateral exercises were performed on both the left and right sides. The guideline provided was 3 to 4 sets of 8-15 reps with focus on slow eccentric contractions. With chronic tendinopathy, progressive eccentric loading has been shown to be beneficial at normalizing tendon structure, which, in turn, can decrease pain.¹⁴

  • IT: Bridges (bilateral and unilateral). Use a Yoga Block between the legs.
  • IT and ET: Standing Hamstring Curl Machine
  • IT and ET: Nordic Drops (IT and ET)
  • IT: Glide Disc Hamstring Curls
  • IT: Sandbag Carries

Stage 3: Isotonic hamstring/gluteal loading with increased hip flexion (70 to 90º). These exercises were initiated in week 3 and were performed every other day depending on the response. Note: unilateral and bipolar exercises were performed on both the left and right sides.  She was advised to aim for 3 to 4 sets of 8-15 reps but to prioritize feeling the correct muscles over the rep scheme.

  • IT: Wall Bridges (an object is crushed between the hands to activate the pecs)
  • IT: Hip Thrusts
  • IT: Lunges (an object is crushed between the hands to activate the pecs)
  • IT: Split Squats (partial weight-bearing prn, hold the kettlebell in the opposite arm as the stance leg to facilitate internal torque.
  • IT: Bipolar Sandbag Dimmel Deadlifts and Staggered Stance Dimmel Deadlifts.
  • IT: Staggered Stance Inner Hamstring Opener
  • IT: Bipolar Sandbag Squats
  • IT: Sandbag Front Squats
  • IT and ET: Unilateral Leg Press Machine. Place foot higher on platform to target the posterior chain.

 

Stage 4: Returning to Splits. This is the most provocative stage, necessitating a conservative approach.

  • Splits were first attempted during week 5 on the Pilates reformer to ensure proper lumbopelvic stabilization. Hip flexion on the front right leg was limited to protect the hamstring tendon.
  • By week 6, the splits were tested every third day (both the right and left sides). Care was taken not to overload the front leg, but to focus on core activation to allow for greater rear leg hip extension. The client was instructed to stop if she felt any symptoms. Note the improvement in the rear leg hip extension: there is more equal loading between the front and rear legs.

 


Gluteus Medius Muscle Activation:

  • ET: Clamshells
  • ET: Jefferson Opener
  • IT: Dynamic Lateral Planks
  • IT: Lateral Planks with top leg hip abduction pulses
  • ET: Isometric Sumo Deadlift
  • ET: Hip Abduction Machine
  • ET: Anderson Squats


Exercises To Improve Rear Leg Hip Extension For the Splits

  • IT: Lumbopelvic Stabilization Exercises to open up the hips
  • IT: GHD unilateral sit-ups to improve hip flexor mobility
  • IT: Cable Glute Kickbacks to improve active hip extension (don’t arch the low back)
  • IT: Active Assisted Standing Splits


VMO Activation:

Phase 1: Closed Kinetic Chain Exercises

Since open kinetic chain exercises triggered right knee pain, closed kinetic chain exercises were initially prescribed. Client was advised to focus on firing the right VMO, and to be partial weight-bearing as needed for the deficit sissy squats.

  • Isometric Quad Contractions (4 sets to failure)
  • Deficit Sissy squats (4 sets to failure). Scale by removing the deficit.
  • Sissy Squats (4 sets to failure)
  • Narrow Stance Squats (4 sets to failure)
  • Pseudo Pistol Squats (4 sets per leg: the exercise is performed on the weaker leg first to failure and then the same number of reps are performed on the stronger leg).

 

Phase 2: Open Kinetic Chain Exercises

These were initiated in week 3. The client was instructed to concentrate on concomitantly activating the right VMO and glute max if she felt any symptoms.

  • Terminal Knee Extension (with a yoga block between the legs to facilitate VMO engagement). 6 sets to failure bilaterally, then 6 sets to failure unilaterally. For the unilateral sets, the exercise is performed on the weaker leg first to failure and then the same number of reps are performed on the stronger leg.
  • Glute Kickbacks. This exercise would cause the client tremendous right knee pain unless she engaged her right VMO. This exercise was selected because it provided her with feedback. (4 sets per leg: the exercise is performed on the weaker leg first to failure and then the same number of reps are performed on the stronger leg). Care was taken not to arch the low back.
  • Cannonball Leg Press (refer to the photo for the foot placement on the platform to target the VMO): 6 sets to failure bilaterally, then 6 sets to failure unilaterally. For the unilateral sets, the exercise is performed on the weaker leg first to failure and then the same number of reps are performed on the stronger leg.


Emotional Release:

Anecdotal evidence from multiple StrongFit assessments by Coach Richard Aceves suggests that low back pain is more prevalent in people who struggle to express anger and frustration. Left low back/spasm has been reported more often in people who are dealing with anger and frustration over the loss of a loved one.

Lumbar Extension Exercise: Moving the lumbar erectors (flexion/extension of the low back) with mouth breathing (to trigger the sympathetic nervous system) has been theorized by Coach Richard Aceves to create safety. When you don’t feel safe, it can lock up the erectors. This can happen when you are unable to express anger. The client reported abatement of symptoms in her left low back after performing a few sets of this exercise, and self-prescribes this exercise as needed.

Phylogenetic Hierarchy Workout: An understanding of the phylogenetic hierarchy allows us to devise workouts that will help restore physiological balance of the nervous system and improve well-being. Although the client’s right proximal hamstring pain was consistently improving, she continued to experience episodic recurrences of left low back pain, sometimes provoked by exercise, other times, completely unprovoked by exercise. Seeking other possible treatment options, the client tried 2 emotional release workouts: Coach Richard Aceves’  Sandbag workout and Coach Julien Pineau’s ET EMOM workout. This consisted of the following sequence:

    • An 80 pound sandbag carry as far as possible in one direction to create a mental battle between fight and flight states. The client was encouraged to “exhale yell” to release frustration to prevent her from prematurely giving up and dropping the bag. She continued the sandbag carry until she dropped the sandbag and fell to her knees (freeze). Note: the client weighs 133 pounds (the sandbag was 60% of her bodyweight).
    • Finding intent to carry the sandbag back. Finding intent allowed her to express frustration. When she was finished, she had entered external torque (SNS) both physically and mentally.
    • The external oblique opener to bring her back into a flow state (to regain control).
    • A couplet of the external oblique opener and Russian kettlebell swings. With each passing set, the kettlebell was pumped more and more (this put her into a fight mode), which allowed her to intensify her feelings (instead of hiding her feelings). This couplet was repeated for as long as it took to express emotion (~3-5 sets). The purpose of the external oblique opener (with long exhalations) was to bring back control (to prevent crashing in external torque).
    • Active stretching to release the left gluteus medius (with emphasis on full exhalations). During the active stretching, she felt the left low back release, but there was no change in the symptoms. When her back released, she was looking at the clouds in the sky, and noticed the clouds were shaped like a spine and pelvis.
    • A brief period of dissociation (resting on the ground for 5 minutes).
    • Immediately after the workout, she felt calm, but her low back symptoms were still present. A few hours after the workout, she was able to emote and cry over the loss of her father to a couple of colleagues. That night she had a dream about her father. She stated that she had struggled to emote regarding this life-changing event. This workout triggered dreams that allowed her to take greater ownership of suppressed emotions that needed to be addressed and released. The next goal was to release these emotions with Coach Julien Pineau’s  ET EMOM.
    • Two days later, she performed the 25 minute external torque EMOM (Every Minute On the Minute) workout consisting of 20 sumo deadlifts, 20 Yates’ rows and 20 incline presses. The goal of this anger-inducing workout was to enter the fight state (achieve a full sympathetic response) to face her anger over her losses and release it. During and after the workout, her left low back pain felt worse, even though she had addressed and expressed her anger and frustration during the workout.  Some may argue she did not achieve the optimal sympathetic response required to fully express her anger and frustration, which is why her low back felt worse. From a mental standpoint, however, she felt instant relief and experienced no delayed onset muscle soreness after this workout, which suggests she did indeed tap into the purpose of workout. The left-sided low back pain was likely exacerbated by her inability to stabilize her spine and pelvis, and this is why she defaulted to her left lumbar erectors. This compensation pattern is more likely to occur with high volume external torque workouts.

Pistol Squat Reassessment:

Prior to commencing treatment, the client had difficulty stabilizing her spine and pelvis when standing on the right leg, and struggled to perform a right-sided pistol squat. She relied on lifters to cheat her mobility, and would compensate with her outer quads. After 6 weeks of treatment, the pistol squat on the right side was re-assessed, and the client was able to successfully stabilize on the right leg and perform a pistol squat in internal torque, barefoot without knee pain. There is still a discrepancy in mobility between the right and left side, but the improvements are indeed noteworthy and exciting.


Discussion:

The symptoms of the right proximal hamstring tendinopathy improved significantly with lumbopelvic (core) stabilization exercises, progressive hamstring and gluteal strengthening, VMO strengthening,  dry needling, and extracorporeal shockwave therapy.

Any limitation to hip mobility typically boils down to lack of stabilization through the core. So other areas become tense to try to provide the stability needed during movement (i.e.  the hip flexors and hamstrings become tense, and this jerks the femoral head up into the hip joint socket to limit movement). So by fixing the core, you can improve stability restrictions and the hips should loosen up. This will improve symptoms in the hip flexors and hamstrings. Prior to initiating the lumbopelvic stabilization exercise program, the client was compensating with her hip flexors and extensors for her weak core. Once she “found her transverse and low abs”, her active hip mobility dramatically increased because her surrounding hip musculature was no longer “tensing up” to perform the stabilizing duties of the core.

By improving the client’s lumbopelvic stabilization, her hip extension active range of motion improved, which allowed her to stop overloading the hamstring in the front leg during the splits. Overloading her hamstring during the splits is the reason why she developed the proximal hamstring tendinopathy.

Improvements in the left low back; however, were not as readily attained and perhaps also required emotional release. Once the client was able to release the emotional content of two painful personal loss experiences, she noted an improvement in her mental state. Two weeks later, she noted a diminution in her left low back symptoms.

We must not overlook the most probable cause of the client’s low back symptoms: her decreased ability to stabilize her spine and pelvis, which is most likely a sequela of deleterious postures adopted during the practice of dentistry. Strengthening the external obliques, low abs, transverse abdominals, right inner hamstring, right gluteus maximus and right VMO significantly improved her back pain.

As previously state, her inability to stabilize the spine and pelvis explains the hip mobility restrictions. The client’s overzealous attempts to push beyond her hip mobility restrictions resulted in proximal hamstring tendinopathy. Both of her chief complaints (left low back pain and right proximal hamstring pain) are likely caused by the lumbopelvic stabilization issue and the weak right inner hamstring, gluteus maximus and VMO.

Emotion may not always play a role in the healing of an injury, but in the event of resistance to healing, it may be worth exploring the emotional implications of chronic pain. The inherent difficulty in measuring emotion and its connection to injury healing is wherein the problem lies. At this time, evidence in support of this concept is purely anecdotal. This case report provides concurring anecdotal evidence that chronic pain and injuries may have both a physical and emotional component, and that spontaneous release of emotion may be necessary in some cases for full healing to occur. Further study is highly recommended.


Learn More From Sara:

LEARN THE SPLITS WITHOUT GETTING INJURED: To learn more about Sara's approach to improving lumbopelvic stabilization and hip mobility so that you can learn the splits without getting injured, click here.

TO GET STRONGER INSTEAD OF INJURED: To learn how to improve muscle deficiencies and imbalances that holding you back from making progress, head over to Sara's Strength Academy by clicking here.

To get Sandbags, click here and use code SS10 for 10% OFF, courtesy of StrongFit Equipment.


References:

  1. Cook JL, Purdam CR. Is compressive load a factor in the development of tendinopathy? Br. J. Sports Med. 2012; 46: 163 -168
  2. Hamming MG, Philippon MJ, Rasmussen MT, Ferro FP, Turnbull TL, Trindade CA, LaPrade RF, Wijdicks CA. Structural properties of the intact proximal hamstring origin and evaluation of varying avulsion repair techniques: an in vitro biomechanical analysis. Am J Sports Med. 2015 Mar;43(3):721-8.
  3. Maurice H. Zissen, et al. High Hamstring Tendinopathy: MRI and Ultrasound Imaging and Therapeutic Efficacy of Percutaneous Corticosteroid Injection [Internet]. American Roentgen Ray Society 2010. 
Level of evidence 2B, grades of recommendation B
  4. Puranen J, Orava S: The hamstring syndrome: a new diagnosis of gluteal sciatic pain. Am J Sports Med 1988;16(5):517-521.
  5. P.BRUKNER & K. KAHN, clinical sports medicine, McGraw-Hill, Australia, 2005 (third edition), P388-390
  6. 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.
Level of evidence 4, grades of recommendation C
  7. Tele Demetrious and Brett Harrop. Hamstring Origin Tendonitis. PhysioAdvisor 2008. http://www.physioadvisor.com.au/9628550/hamstring-origin-tendonitis-hamstring-injury-p.htm
 Level of evidence 5, grades of recommendation D
  8. Proximal Hamstring Tendinopathy. Physiopedia. https://www.physio-pedia.com/Proximal_Hamstring_Tendinopathy
  9. Jayaseelan DJ, Moats N, Ricardo CR. Rehabilitation of proximal hamstring tendinopathy utilizing eccentric training, lumbopelvic stabilization, and trigger point dry needling: 2 case reports. J Orthop Sports Phys Ther. 2014 Mar;44(3):198-205.
  10. Fredericson M, Moore W, Guillet M, Beaulieu C.High hamstring tendinopathy in runners: meeting the challenges of diagnosis, treatment, and rehabilitation. Phys Sportsmed. 2005 May;33(5):32-43
  11. Philippon MJ, Ferro FP, Campbell KJ, et al. A qualitative and quantitative analysis of the attachment sites of the proximal hamstrings. Knee Surg Sports Traumatol Arthrosc. 2015;23:2554-2561
  12. Rio E, Moseley L, Purdam C, et al. The pain of tendinopathy: physiological or pathophysiological? Sports Med. 2014;44:9-23
  13. Goom T, Malliaras P, Reiman M, Purdam C. Proximal Hamstring Tendinopathy: Clinical Aspects of Assessment and Management. Journal of Orthopaedic & Sports Physical Therapy, 2016 Volume:46 Issue:6 Pages:483–493
  14. Öhberg L, Lorentzon R, Alfredson H.  Eccentric training in patients with chronic Achilles tendinosis: normalised tendon structure and decreased thickness at follow up. Br J Sports Med.  2004; 38: 8– 11.

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Dr. Sara Solomon is the creator of the Fat Loss Fast System about Intermittent Fasting and Flexible Dieting. She has degrees from McGill University in dentistry (DMD) and physical therapy (B.Sc. PT). She is also a certified StrongFit Coach, CrossFit Level 1 Trainer, ACE personal trainer, NASM fitness nutrition specialist, Mad Dogg Spinning Instructor, Level 2 Buddy Lee Jump Rope Trainer and Ambassador, a Team Bodybuilding.com and BSN athlete, and a retired WBFF PRO Fitness Model. Her passion is teaching others how to fuel and move well.

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