Hamstrung: Hamstring Strains and Posterior-Thigh Pain in Runners

Stay the CourseWhere do ideas for Stay The Course come from? Unfortunately, I don’t have a giant hopper filled with topics that I pluck from each month (though perhaps we might create such a hopper from questions from iRunFar readers someday soon). Instead, topics come from salient issues or concepts I come across – either in the clinic or on the trail.

This month’s is no different. As a clinician, it is common to “get runs.” (No, not those “runs,” or those “other runs!”) To clarify: a clinician’s “run” is a cluster or succession of patients who have a similar issue.

The injury du jour? Hamstring pain!

Hamstring – or posterior-thigh pain – is less common than, say, lower leg or knee pain, but it is a frequent issue for many runners. And it’s an issue we tend to see in the summer, perhaps when we’re starting to run faster and farther, and in the winter, when cooler temperatures make tissue flexibility more challenging.

But what is it, really? Why does it happen? And how do we recover from and prevent it?

Posterior-Thigh Pain: Differential Diagnosis

Hamstring strains are over-diagnosed nearly as frequently as plantar fasciitis. In fact, until recently, I didn’t believe distance runners ever truly had hamstring strains.

There are three primary causes of posterior-thigh pain: hamstring strain, referred sacroiliac-joint pain, and “sciatica”, or peripheral nerve tension referral.

Hamstring Strain
Yes, to strain a hamstring as a distance or long trail runner is possible, even if one avoids fast running. Signs of a true hamstring strain include:

  • Range of motion loss in the hamstring (both straight-knee and bent-knee raise testing)
  • Palpable soreness somewhere along the length of the muscle-tendon
  • Pain with end-range stretching and/or resisted testing, i.e. it hurts to stretch it or strengthen it

Referred Sacroiliac-Joint Pain
Referred sacroiliac (SI) joint pain is a substantial and frequent cause of posterior-thigh pain. In fact, the common referral pattern of SI pain closely mimics that of hamstring pain. Signs of SI joint pain include:

  • Pain with applied pressure to the SI joint (the “bumps” just below the waist band in the posterior pelvis); this is usually described as the “starting point” of the pain.
  • Sometimes a range of motion loss with a straight-leg raise, but often an absence of pain with bent-knee testing.
  • A general lack of “a sore spot” in the hamstring, or posterior-thigh tissue, i.e. you poke around but can’t seem to find it

“Sciatica,” or Peripheral Nerve Tension Referral
Referred nerve-tension pain closely mimics hamstring-muscle pain; and often, it accompanies it. If the sciatic nerve is either adhered or compressed in its travels from the spine to the leg, it can cause pain anywhere along the length of that nerve (as we discussed in the Achilles pain column). The posterior pelvis, buttock, and thigh are common areas of sciatic nerve referral. Signs of nerve pain include:

  • Pain with straight-leg raise testing (but significantly less with bent-knee hamstring stretching)
  • Usually (but not always) a lack of tenderness in the posterior thigh
  • Usually a lack of pain with resisted testing, i.e. strengthening the muscle doesn’t hurt
  • Nerve-like symptoms, including ache at rest, buzzing, tingling, or any other “electrical” sensations

Neither SI joint nor sciatic-nerve pain in the posterior thigh will be discussed in this column. However, many of the recommendations for relieving hamstring pain will result in decreased pain in these areas, as well.

Why the Hamstring?

The hamstring has three primary actions in the running stride:

  • It helps extend the hip (but weakly, unless you’re sprinting) in push-off.
  • It helps lift the leg upward in the drive phase.
  • It helps slow the foot at and before initial contact.

There are two primary reasons for hamstring tightness and dysfunction in athletes: compensatory overuse and over-lengthening.

Compensatory Overuse
At my new clinic, we have a variety of interesting toys, high-technology diagnostics and biofeedback instruments that are extremely useful in identifying how people move. One useful tool is electromyography (EMG), using surface electrodes to measure the relative activation of muscles during functional movements.

What we frequently find clinically in patients with hamstring pain is excessive hamstring firing to compensate for deficient activation of the gluts. The gluteal muscles are the strongest hip movers; the glut max is one of the strongest muscles in the body, and it is primarily responsible for extending the hip. And since hip extension comprises half of the gait cycle, this is an important action!

But when the gluts fail to powerfully activate, the hamstring, a weak hip extender, tries to help out. And when this imbalance occurs, what we see are sky-high EMG values for the hamstring, and relatively little for the gluts with hip-extension testing.

In non-endurance athletes, such as sprinters and weightlifters, we tend to see a weak glut on the same side as the painful hamstring. Makes sense: glut’s not doing its share, so the hammy kicks in. But with distance runners in particular, what we see in folks with hamstring pain is the weaker glut is on the opposite side!

But why?

Recall The Three Injury Rules: For every injury action, there is an equal and opposite reaction.

If you believe the run stride is two actions: one leg pushes beneath and behind, and the other leg drives upward and forward, then a deficient push (hip extension, glut muscle action) on one side will result in overstress of the drive (hip flexion, hamstring curl) of the opposite leg.

We saw this plainly in a recent EMG study of one of my hamstring-pain runners: she had left-hamstring pain, and a nearly nonexistent right glut activation. To reiterate, if you have a push problem on one side, you’ll create a pull problem on the other side. In this runner’s case, her lack of glut activation (and overall push-off) on the right was a major factor in her left-sided hamstring pain.

Regardless of which side is weak, heavy emphasis on selective glut activation is important for both performance and pain relief.

Over-Lengthening

This is arguably a more common cause of chronic tightness and pain in distance runners. The hamstring plays a substantial role in “slowing down” the foot at the end of the swing phase, as it readies to contact the ground. If the stride is, for some reason, too long, or if the stride has inadequate hip flexion and the hamstring is “stuck” in a constantly lengthened state, the hamstring gets over-stretched and over-worked with each stride.

Initial Treatment Strategies

Conventional sports-medicine strategies are important for the initial treatment of hamstring pain. If acute, RICE is required. If it is sub-acute or chronic, the following basic strategies are helpful for initial treatment:

  • Soft tissue mobilization – either self-mobilizing with a ball or roller, or from a licensed massage therapist.
  • Gentle range of motion – restore normal length with passive and active stretching. But avoid over-stretching, as strains, by true definition, are tissues that have been excessively stretched.
  • General strengthening – low-intensity, general hamstring strength exercises emphasizing both concentric and eccentric exercise are helpful in the initial stages so long as it does not increase pain beyond the exercise bout.

However, to perform conventional sports medicine alone will only result in temporary relief. More specific strategies are required for sustained relief and recovery.

Run-Specific Treatment Strategies

To fully recover from hamstring pain and prevent recurrences, it is paramount to do the following:

  • Restore full strength and range of motion to the hamstring itself.
  • Restore normal muscle-activation patterns. Namely, activate the gluts!
  • Restore efficient gait mechanics to prevent over-use or over-lengthening stresses.

1. Combined Hamstring Plus Glut Strengthening
The following are two of the more effective, evidence-based hamstring – and glut – strengthening exercises, specific to running:

A. Chair Bridges

Position yourself on the floor beside a chair, couch, or table, with heels resting on the edge. To achieve some glut activation, flatten the back into the floor, then preemptively squeeze the gluts. Then, slowly lift the pelvis. This is a powerful activator of the hamstrings, yet you should also feel the gluts working hard.

Chair Bridge Start

Chair Bridge Start

Chair Bridge Double Up

Chair Bridge Double Up

It is important to keep the back flat, as a common muscle imbalance is over-use of the lumbar extensors to extend the hip, which causes both hamstring and low-back pain.

To make this exercise more challenging, perform with a single leg.

Chair Bridge Single Up

Chair Bridge Single Up

Hold 3 to 6 seconds. Perform two to three sets of ten reps, once or twice daily.

B. Bridge Walk-Outs

Position yourself flat on the floor, with knees bent and feet flat. Flatten your back, pinch the gluts firmly, and boost up the pelvis 4 to 6 inches. Then slowly “walk-out” each heel until the legs are nearly straight. Slowly return. A typical repetition involves 4 to 5 “steps” with each leg. Emphasize pelvic stability by keeping it level throughout the exercise.

Bridge Walkout Start Up

Bridge Walkout Start Up

Bridge Walkout Extended

Bridge Walkout Extended

To make this exercise more challenging, when the legs are nearly fully extended, lift one leg straight upward about a foot. With the other leg, “reach long” with the heel, pushing it into the floor. Alternate, then return.

Bridge Walkout SLR

Bridge Walkout SLR

Perform two to three sets of 10 reps, once or twice daily.

2. Selective Glut Activation – The Running Pattern

This next exercise is extremely important in selectively activating the glut muscles – as well as the abdominals – within the running pattern.

Recall The Power Position from “The Fall Guy” column last November:

Power Position BOTH

The “Power Position,” demonstrating the prolonged holding of both the push-off (lengthened) and driving (shortened) leg positions.

This represents a prolonged hold of The Running Pattern, which emphasizes the push-off and the drive phase of the running gait.

Emphasizing the trunk elongation (as noted by the downward tilting pelvis) on the stance leg effectively facilitates glut firing. A normal activation pattern involves the runner “feeling” the glut begin to “burn” within 1 to 2 seconds of holding this position. If you do not feel the glut working, hold the position until you do, or as long as you can.

Once the glut firing (signified by that burn) is effectively and quickly perceived, hold this position for six seconds, repeating the same side in succession, 4 to 6 times. Perform this exercise once or twice daily, including before a run.

3. Restoring Efficient Gait Mechanics

Once the hamstring is strengthened, and the gluts turned on, it is time to address stride efficiency.

To be certain the glut is the prime mover in push-off, and the hamstring is not being over-lengthened in initial contact, it is important that the stride be both powerful and compact.

Performing marching and skipping drills, emphasizing The Running Pattern – namely the strong, compact upward and downward action of the hips – will facilitate the gluts to push off. Equally important, this compact pattern will ensure that the foot lands directly beneath the trunk at initial contact, sparing any over-lengthening stresses.

Perform this drill for 3 to 4 bouts of 10 to 15 seconds, immediately before running as part of your warm-up.

In Conclusion

Hamstring strains and pain yet again require the trifecta of treatment strategies for full recovery:

  • What is it, really? As always, find out for sure what it is. Never assume, until all other factors are ruled out. Treating a SI problem with hamstring exercises will keep most people off the roads and trails, far longer than necessary.
  • Pain control. Restore normalcy to the tissue. Any injury requires adequate pain control. Sometimes this is literally no off-time; it’s simply correcting the dysfunction, be it neuromuscular or motor control. But often, it takes significant rest and a well-balanced rehab approach. Be patient!
  • Get to the bottom! What is it about your stride that causes this? The vast majority of running injuries are inefficiency issues. What’s yours, and how can you correct it to relieve the stress and pain?

And lastly, the good news about treating all running injuries, the elusive Fourth Law of Running Injuries:

Any treatment approach that fully and sustainably resolves pain will invariably make you faster (The Efficiency Law).

You run more efficiently, and you run faster and hurt less. It’s that easy, right? Win-Win!

Good luck!

Call for Comments (from Meghan)

  • Who has experienced a diagnosed hamstring strain from endurance running? How did the injury originate for you?
  • For those who have worked through the recovery for a hamstring strain, what among Joe’s suggested exercises/treatments worked well for you? Are there other exercises/treatments that worked for you and that aren’t mentioned here?
Joe Uhan

is a physical therapist, coach, and ultrarunner in Eugene, Oregon. He is a Minnesota native and has been a competitive runner for over 20 years. He has a Master's Degree in Kinesiology, a Doctorate in Physical Therapy, and is a USATF Level II Certified Coach. Joe ran his first ultra at Autumn Leaves 50 Mile in October 2010, was 4th place at the 2015 USATF 100K Trail Championships (and 3rd in 2012), second at the 2014 Waldo 100K, and finished M9 at the 2012 Western States 100. Joe owns and operates Uhan Performance Physiotherapy in Eugene, Oregon, and offers online coaching and running analysis at uhanperformance.com.