The Effects of an Eccentric Focused Rehabilitation Program on Proximal Hamstring

Tendinopathy in Ultra Runners

Research Team
Chandler Copeland, ATS
Brandon Surber, ATS
Beth Funkhouser, Med, LAT, ATC, CSCS
Melissa Davis, MA, ATC-L
Hannah Clementson, LAT, ATC
Chaypin Buchanan, LAT, ATC

12/04/2017
 Table of Contents
CLINICAL SCENARIO .............................................................................................................................................. 2
FOCUSED CLINICAL QUESTION: ............................................................................................................................................ 2
KEYWORDS:.............................................................................................................................................................................. 2
SUMMARY OF SEARCH METHODOLOGY ........................................................................................................ 3
SEARCH STRATEGY: ................................................................................................................................................................ 3
SOURCES OF EVIDENCE SEARCHED: ..................................................................................................................................... 3
BEST EVIDENCE REVIEWED: ................................................................................................................................................. 4
CLINICAL BOTTOM LINE ...................................................................................................................................... 4
IMPLICATIONS FOR CLINICAL PRACTICE ............................................................................................................................. 5
RECOMMENDATIONS FOR FUTURE RESEARCH .................................................................................................................. 5
REFERENCES: ........................................................................................................................................................... 5

1
CLINICAL SCENARIO
Proximal hamstring tendinopathy (PHT) is a fairly new, unresearched topic that is affecting
athletes competing in long distance sports with a lot of miles on their legs. This research first
began in Fall of 2016 when a project was introduced in an Advanced Strength and
Conditioning course. The two students were to meet demands of a client that happened to be
an Ultra Runner suffering from PHT. This clinical question is used as an adjunct for research
to further the students’ knowledge about the topic and possible rehabilitative ideas to use in
the Spring of 2018.

Development of Clinical Question:

As stated above, the basis for this clinical question came from an advanced strength and
conditioning project that was assigned to us in the Fall of 2016. We followed that project by
deciding to spend most of last year formulating clinical questions that would allow us to
investigate the issue of PHT. We ended up looking at biomechanical implications of tight hip
flexors on PHT it ultra marathoners. We have been looking at other ideas for addressing the
issue of PHT and came across some research indicating the use of eccentric exercises to
address those individuals suffering from the condition. We cross referenced this with research
on tendinopathy in endurance athletes and the effects of eccentrics on individuals suffering
from various tendinopathies to create a research base for the use of eccentrics in addressing
PHT in ultra runners.

Development of Investigation Committee:

We selected Athletic Trainers on campus that have athletes experiencing PHT. By doing this
we can begin to make a population base for the Spring in which we can begin another
experiment. We decided to take this fall off from experimentation and focus on research
because of in season sports as well as difficult class schedules. The Athletic Trainers we have
selected all carry their own personal rehabilitative experiences for how they rehab PHT and
will be able to provide helpful opinions.

Focused Clinical Question:

How does an eccentric focused rehabilitation program affect proximal hamstring
tendinopathy in ultra runners

Keywords:
Proximal
Hamstring
ultra runner
tendinopathy

2
 tendinosis
eccentric
strengthening
rehab
fix
run

SUMMARY OF SEARCH METHODOLOGY

We began by breaking down or previous approach to addressing the issue and looking for
new avenues to explore. One thing that kept coming up during our research last year was
eccentric training for hamstrings injuries. We began by searching Google for some very
general information and were overwhelmed with articles. Knowing that we had a good idea,
we moved onto scientific journal databases and began looking for information on PHT and
eccentrics. We found a few articles directly related to our subject, but many that revolved
around general hamstring injuries and eccentrics as well as articles that linked endurance
and speed athletes with these injuries. The end result was our combining of these bodies of
research to develop an evidence based approach to addressing PHT with eccentric training.
We have discussed these ideas with our committee some, but plant to discuss implementing
this plan with the athletes they have presented next semester in an attempt to create our own
body of evidence.

Search Strategy:
P- Ultra runners
I- Eccentric exercises
0- Faster rehabilitative process with greater hamstring strength

Sources of Evidence Searched:

Medline complete
IJSPT
NCBI
Tendinopathy Rehabilitation

3
Best Evidence Reviewed:
Conservative Treatment of Subacute Proximal Hamstring Tendinopathy Using Eccentric
Exercises Performed With a Treadmill: A Case Report- two MDs conducted a case report on a
34 year old male triathlete with unilateral proximal hamstring tendinopathy. The
tendinopathy was diagnosed by ultrasound and his pain was present only with running and
prolonged sitting. The patient was put on a 12 week program that introduced eccentric
exercises at week 4 when no progress was being made. The eccentric intervention involved
utilizing a treadmill to create an resisting force while the muscle was lengthening. The patient
was instructed to stand on the treadmill with the affected leg on the belt while in hip
extension and slight knee flexion. The treadmill was then turned on at a low speed while the
patient was instructed to actively resist the movement of going into hip flexion. By week 8 (4
weeks of eccentric training), the tendinopathy was no longer visible by diagnostic ultrasound
and pain with sitting was absent. By the 12th week of the program (8 weeks of eccentric
training), the patient was able to run 5km without pain and able to participate in interval
training. Throughout the experiment, the treadmill speed was unchanged and the patient
noted that the pain decreased within 2 weeks of beginning eccentric exercises. Further study
with a larger population is needed to have more conclusive results.

Hamstring Injury Rehabilitation and Prevention of Reinjury Using Lengthened State Eccentric
Training: A New Concept- Two dual physical therapists/athletic trainers and one PhD
conducted a research study to investigate the use of lengthened state eccentric training in
patients suffering from hamstring injuries (particularly strains). They identified different
mechanisms that can contribute to different strains such as proximal semitendinosus injuries
that can lead to chronic conditions. There has been a large body of research focusing on the
use of eccentrics in the prevention of hamstring injuries, but this group wanted to look into
the effect of eccentrics on rehabilitating hamstring injuries and preventing future re
injury/chronic injuries. Specifically, this study looked at the use of eccentrics while the
hamstring is in a lengthened state. Due to the occurrence of hamstring strains in high speed
athletes, a theory was developed that hypothesized that the eccentric loading of the
hamstring at end ranges of motion during high speed running leads to strains. This ultimately
leads to the athlete losing strength at these end ranges and, if not addressed with targeted
training, can lead to reinjury or chronic issues. Evidence suggests that a rehabilitation
program consisting of eccentric strengthening while the hamstring is maximally lengthened
can help athletes regain strength lost to injury and can further prevent re injury.

CLINICAL BOTTOM LINE

Eccentric exercises used to rehabilitate the proximal hamstring have a significant positive
impact on the healing process. The hamstring while in a lengthened state is the weakest point
and also most likely to fall subject to injury. By strengthening through eccentrics, the patient
is able to gain hamstring strength that is also effective at full length causing a decreased risk
of injury. Eccentric exercises in general have been proved to cause a greater increase in
muscle fiber recruitment and cause a decreased incidence of injury. We believe this is the key
to rehabilitating the proximal hamstring and decrease the prevalence of the injury altogether.

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Implications for Clinical Practice
PHT is a significant problem in long distance athletes that does not have a concrete protocol
for rehabilitation. The necessary rehabilitative process is somewhat unknown and needs to be
further researched to reach the best outcome. By participating in this research, we can help
the Athletic Training world in finding a concrete rehabilitative measure to combat this
underlying issue. Next Spring we will use this research for evidence based practice.

Recommendations for Future Research

We are now looking to recreate other experiments with a larger population of our own in an
effort to tackle the hamstring pathology with eccentric exercises. Unlike the past, when we
have looked to rehabilitate the surrounding tissues to alleviate the stress upon the hamstring,
we are planning to take a new approach this time. Also with a slightly larger population, we
will have more concrete results.

REFERENCES:
Daniel Cushman, Rho Monica E. Conservative Treatment of Subacute Proximal Hamstring
Tendinopathy Using Eccentric Exercises Performed With a Treadmill: A Case Report .
Journal of Orthopedic & Sports Physical Therapy. 2015;45(7).

Schmitt B, Tim T, McHugh M. Hamstring Injury Rehabilitation and Prevention of

Reinjury Using Lengthened State Eccentric Training: A New Concept.
International Journal of Sports Physical Therapy . June 2012:331-341.

Malliaras P. Top Tips for Proximal Hamstring Tendinopathy Rehab. Tendinopathy

Rehabilitation . April 2016.

Lempainen L, Johansson K, Banke IJ, et al. Expert Opinion: Diagnosis and Treatment of
Proximal Hamstring Tendinopathy. Muscle, Ligaments and Tendons Journal . March
2015:23-28.