Hamstring Tendinopathy: Sample Rehabilitation Program Videos

Audience: Therapists and Patients Purpose: This post is video overview of the sample exercise progression I might advocate for patients (primarily runners) who present with persistent longstanding high hamstring pain.


Runners, particularly faster runners, will often present with high hamstring tendon pain.  The pain is typically felt where the muscles insert into the bottom bone of the hip (the ischial tuberosity).  In addition to the hamstrings the adductor magnus can often be involved.

Patients will feel pain with running (particularly at speed), pain when pulling their shoe off with the foot, often pain with sitting and even some pain getting out of a chair.  When I see these patients they have often had this condition for months or years.

When the pain has been around for months you may want to consider this dysfunction a failed healing response.  Throw the ideas about inflammation out the window.  These patients have rested their leg and even done some remedial exercises but to no avail.


The exercise approach is simple – TISSUE RESPONDS TO LOAD.  Injury treatment is the judicious application of stress – applying this stress to an injured tissue is stimulus for adaptation.  This application of stress to the  non-responding tissue (i.e. your hamstrings) can be complimented with all other treatment techniques and assessments.  In addition to applying stress we also want to try the find the cause of the initial hamstring overload (Good luck).  Some possibilities being:

1. Weak glutes

2.  Poor trunk strength/endurance/control

3. Restricted joints anywhere (feet, fibular head, SI joints, Thoracolumbar junction)

4. Excessive anterior tilt while running (motor control or tight passive/active tissues?)

5. Overstriding

6. Understriding and “hanging” on to your hamstrings when running (rare)

7.  The big daddy – too much, too soon, for you at that point in time.

8. Poor tissue quality (sometimes our muscles and tendons just need a little rubbin’ lovin’  e.g. ART, myofascial, Gua Sha, Acupuncture, general massage)

OK, enough lecturing, you are still in pain

My clinical take is that many athletes get issues 1-8 somewhat taken care with usual care. (This assumes it is not crappy run of the mill care where someone sticks ultrasound and a TENS machine on you and then tells you to stretch). After the usual care (which is the non-horrible kind) patients are then given remedial exercises for the hamstrings (stretching, bridges, curls) but they still aren’t responding.

With these recalcitrant cases we often then need to stress the tissue harder (or find the other key link in the dysfunction).  Inspired by the painful eccentric loading protocol’s variable success in tendon pain (a nice review here and here) I choose to ignore some of the eccentric loading exercises alone and also add heavy resistance training.  For my patients, eccentric loading means that you just work a muscle as it gets longer not as it gets shorter.  It is like lowering a weight but never picking it up again.  It never made sense that concentric exercises would negate the benefits of eccentric exercises and why would daily loading be necessary? (Update: I should listened to  Jill Cooke's podcasts (search on itunes if you care), she is an amazing tendon researcher and has been saying this for a long time).  I had good success with heavy resistance training  but did not have any research to support it.  Fortunately, I found some (click here on a comparison of heavy resistance training versus painful eccentric loading), so I can go back in time and support my previous views and say I was evidenced-based(this is definitely some confirmation bias on how I select the papers that I read).


Here are some exercises that I often recommend for runners

A warning, don’t do these willy nilly.  Have your therapist or strength and conditioning coach guide you through these exercises and create the appropriate parameters (how much, how often etc).  Not all of these exercises are meant to be done on the same day.  Work with a professional to create a program.  You can also be doing a lot of other exercises for your core or upper body.

If you are my patient and aren’t sure, email me.

Stage One (2 weeks)

Rationale: Train the glutes, get the  hamstrings ready for more load, train the trunk, say hello to the external hip rotators

Bridge Series (Front to Side)



Back Bridge



Bird Dog





Squats with External Rotation



Perform the squat as seen in the video below but have tubing around both knees.  When squatting down attempt to press the outside of your knees against the tubing.

The squat in the video is not ideal.  You DO NOT want the knees to start the motion.  The first motion is the butt going backwards with the weight through the heels and the balls of the feet.  The squat starts with a bow or a “hip hinge”.

Hip Flexion Drives


Put a cable or tubing around your knee.  Drive your knee forward training your hip flexors.  If you can do 15 easily then add more weight.  Try to not let your spine bend forwards or backwards.

Cabled Hip Extensions


This exercise attempts to mimic the function of the hamstrings during running.  The hamstrings and glutes work to pull the swinging leg backwards toward the ground and support your weight during foot strike.  Hamstring strains occur during this phase.  Click on this link for a post about hamstring function during running (click here).

With this exercise you want a cable or tuning tied around your ankle.  You then pull your leg backwards with your butt and hamstring and slowly return your leg back to the start.  Try not to arch your back during this exercise.  Focus on feeling tension in your hamstrings and glutes.  You will also feel this in the leg that is standing on the ground.  For balance it is OK to grab onto something while doing this exercise (it will also take the strain off the leg that is on the ground).

Stage Two Learning Phase(weeks 2-6)

Repetitions: 8 to 12 (2-3 repetitions shy of muscle failure or form breakdown)

Sets: 1-2


Bridge Series (Front and Side)


Back Bridge Walkouts



Deadlift Learn (light weights)



One Leg Deadlift



Hip Airplane



Cabled Hip Extensions

Cabled Hip Flexion

Stage 3 (weeks 6 to 12)

Repetitions: 4 to 8 (1-2 repetitions shy of muscle failure or form breakdown)

Sets: 2-3

Nordic Hamstring Curls



Bridge Series (Front and Side)

Single Leg Bridge Eccentric Slide Outs



One Leg Deadlift

Hip Airplane

Cabled Hip Extensions

Cabled Hip Flexion

Running Biomechanics: The knee is NOT flexed by the hamstrings

Audience: Therapists, Trainers & Runners

Main Point: The hamstrings do NOT significantly flex the knee at toe-off.  In other words, runners do not consciously flex their knee when they are running and training this is most likely folly.  I have read a number of chiropractic and physiotherapy running "experts" who advise people to actively flex their leg off the ground and keep it flexed so as to change the moment of inertia about the thigh when someone is running.  The idea is to get the weight of the leg closer to the hip joint so it is easier to swing the leg forward. The problem with this idea is that the hamstrings do not do this when you are running.  Knee flexion occurs passively. It is a result of the hip flexing rapidly and powerfully. While the knee is flexing the quadriceps are actually active.  They are acting to control the amount of knee flexion.  This is what puts strain on the rectus femoris.

The Evidence

We can look at two things:  a kinetic analysis of running (the forces that are produced by and acting on the body) and EMG studies.  One note,  there is some research showing the short head of the biceps femoris is active at early swing and late stance suggesting that flexes the knee.  However, this is one of the limitations of EMG - just because a muscle is on we can't assume that we know what is doing.  The Kinetic analysis is what gives us insight into what the muscles are doing.  And it is the power and moment (i.e. joint torques) analysis that shows that the knee is not actively flexing but rather it is being passively flexed.  The EMG activity of the short head of the biceps femoris may be providing some other function rather than an as a primary mover. For example, it may be functioning to decelerate the forward rotation of the tibia while the tibia is on the ground.

Kinetic Analysis of the Knee

Knee function during swing and toe off

Ralph Mann and David Winter investigated this more than 30 years ago (click here) and more recently Anthony Schache did a wonderful paper looking at the 3D kinetic analysis of running at different speeds (click here).   What they and others (Cavanaugh) found was that at toe off power is primarily generated at the hips (flexion) and at the ankle (plantar flexion).

To quote a paper by Ralph Mann (1980):

"The majority of flexion is probably secondary to rapid acceleration of the thigh during the initial swing phase and the foot and tibia sort of follow along, bringing the knee into maximum flexion"

After toe off, a knee extension torque develops during the first half of swing (even though the knee is flexing, the quads are working to control this flexion) and power is being absorbed.  A knee flexor torque develops during the last half of swing and power is generated (the hamstrings work to flex the knee in preparation for ground contact).

Simplified version of Knee function during stance

At the knee, there is an extensor torque during most of stance with a slight flexor torque just prior to toe off.  Power is absorbed during the first half of stance (the quads work eccentrically for shock absorption) and power is generated during the latter half of stance. But...

Are the knees helping you push off during running?

Not as much as you think.  The knees really just absorb impact and stop you from collapsing and generate some power during late stance.  What Dr. Schache's study strongly shows (as with previous work as well) is that with an increase in speed there is no greater work done at the knee joint ratherit is the increase in hip flexor power and to some extent plantar flexor power that is associated with an increase in running speed.  Dr Mann suggests that the knee extension during late stance is again a product of the opposite hip pulling the body forward and over the foot still on the ground causing knee extension.

During sprinting something different happens...the second period of knee extension during stance does not occur.  Rather there is a slow progressive amount of knee flexion during the stance phase.  The sprinter does not have sufficient time to absorb shock at the knee (the shock is absorbed at the ankle).

This finding was also supported by the McClay and Cavanaugh who investigated the extensor paradox.  These researchers (in the book "The Biomechanics of Distance Running" Chapter 6) found that knee extension was occurring more than 120 ms after the quad muscles had shut off.  This is more of time delay than can be expected from the electromechanical delay of muscles (this delay is the time it takes a muscle to turn on, take up the slack of the muscle and then exert force on its attachment).  Therefore, something else besides quadriceps force was creating knee extension during late stance.

EMG during Running

The graph below shows the average muscle activity during running and then sprinting.  Note how the extensor muscle groups are decreasing their activity by late stance and toe off (Source Mann et al 1986).  This has previously been called the extensor paradox.   Power analysis (inverse dynamics) tells us that the leg extension may be coming from another source which is mostly likely hip flexion of the opposite limb.



The bars below denote when the muscle is on and at what point in time in the gait cycle.  T.O. means toe off.

The Bottom Line

The function of the hamstrings as a primary flexor of the knee joint during toe off and the swing phase is overrated.  This is a passive activity.  Kinetic analyses and EMG studies suggest that the hamstrings are more importantly functioning to control the knee during late swing to bring the foot back to the ground.  This role is coupled with their role in extending the hip during late stance.  Another, important function that is highly related to increasing running speed.  A future post will explore the function of the hip during running.

Greg Lehman