Case Study: Hamstring Tendinopathy In Professional Distance Runner

There are too many abstract discussions in the performance space these days about how to train and rehabilitate athletes. These circular arguments usually yield nothing substantive or actionable because providers spend too much time defending their ideology and trying to articulate why they are in the right instead of just being transparent and “showing their portfolio”. As an example, investors should demand that financial advisers share their own portfolios instead of pontificating about macroeconomic theory. Words matter but what people do when they have skin in the game reveals more about them than their explanatory justifications for said actions. 

The point of these case studies is not to suggest that what we did in any of these situations is particularly good. If we’re being honest, we don’t always have robust outcome measures to suggest that what we do really “works”. More often than not, we default to the eye test. We coach and own our decisions. The intent here, therefore, is to be completely transparent about what we did when an athlete’s time, money, and readiness was at stake in hopes that other providers share their experiences and contribute to a more genuine collective conversation.


Female professional distance runner (event withheld to protect identity) with left hamstring tendinopathy x 2 months that kept her from running more than 10 miles a week during that period. Athlete also works full time as a medical researcher and is currently applying to medical school. Athlete had substituted running volume with swimming and biking to avoid symptom provocation and maintain training load. Athlete reported for her initial evaluation with us in late March 2019 with the goal of competing at the USATF Championships in July. She had received treatment (mainly manual therapy) from other providers prior to her evaluation with us and reported transient relief but nothing that allowed her to increase her running volume to normal levels.   


  • Time: 4 months to prepare for nationals after not running more than 10 miles/week at low intensity for the previous 2 months
  • Financial: Athlete did not have out of network insurance benefits so paid completely out of pocket for treatment. Regular treatment sessions were not within her budget (nor were they particularly necessary in our opinion) so we saw her as the last patient of the evening but only charged her for a single hour to achieve all the treatment and programming objectives in a single session. We created a home program and corresponded completely via email or text for the remainder of the plan of care.
  • Interpersonal Factors: Model athlete in terms of enthusiasm and motivation to prepare and compete. The biggest obstacle here was convincing her that she wouldn’t necessarily benefit from seeing multiple providers for specialized forms of treatment as she had done in the past when a more global approach, perhaps one that included some forms of manual therapy, was likely warranted instead.

Evaluation Findings

  • No pain with manual resisted knee flexion or hip extension. Self-reported pain at proximal left hamstring attachment after running on a hard surface for more than a few minutes.
  • Tender to palpation at proximal hamstring attachment 
  • Orthopedic testing/gross movement: limited hip extension left, limited hip internal rotation left, limited hip adduction left
  • No significant medical or surgical history
  • Analysis of running mechanics on self-powered treadmill didn’t reveal anything that we thought warranted change. Athlete accumulated 15 minutes of running on treadmill with no symptom provocation. This finding was diagnostic and influenced programming in itself.
  • Athlete revealed what her ideal training week looks like when completely healthy. The plan of care attempted to mirror that template as closely as possible with minimal symptom provocation while also addressing some of the general abilities that were lacking. We attempted to achieve this objective by manipulating running surface (self-powered treadmill runs replaced runs on pavement), incorporating strength work, and adding elastic work (via A Runs) that reinforced a more vertical, less provocative footstrike pattern than occurred during normal running. 

Plan of Care Movement Prep (Daily)

1. Hip Shift Hamstring Bridge Reps - YouTube - 2x10, left side only
2. Couch Stretch from Wall - YouTube - 50 butt squeezes/side
3. Single Leg Squat with Hip Shift - YouTube - 2x6-8, left side only

Strength (2x/week)

A1 Glute Ham Raise - YouTube - 3x good form, partial range of motion
A2 Rear Foot Elevated Split Squat - YouTube - 2x6-8/side, goblet hold for resistance
B1 Swiss Ball Hamstring Curl - YouTube - 2x moderate fatigue/side, feet on concept 2 rower, 1 leg eccentric/2 leg concentric
B2 Bench Side Plank Extended - YouTube - 2x30-60s/side, choke up to just below knee, when you can hit 60s on both sides choke down

Weeks 1-2 Day 1 - Self-powered treadmill run (easy, max 30 mins, can be broken up into sets based on feel/symptoms) Day 2 - A Run, 15s on/45s off, try for 30 mins (to simulate a higher intensity, lower volume run) Day 3 - Strength, strides on self-powered treadmill Day 4 - Incline Treadmill Walk (max out at 25% grade), 25lb vest, RPE of long run when healthy, 60-90 mins to replace weekly long run Day 5 - Strength, strides on self-powered treadmill Day 6 - Normal outdoor run (easy) Day 7 - Rest Week 3: Same as weeks 1-2 but replace Day 2 w/interval run or “workout” on turf in flats Week 4: Same as week 3 but replace Day 1 w/outdoor run Weeks 5+: Patient reporting being symptom free at this point. Resume normal weekly training template but adjust volumes and interval splits to account for current level of preparation/fitness. Continue to maintain strength work 1x/week. Athlete ultimately was able to compete in the USATF championships without additional setbacks.

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