Proximal Hamstring Tendinopathy (PHT)


What is it?

A tendinopathy is a change in the tendons structure, usually in response to overload. Unlike what was previously thought, there is no real inflammation happening. The pain is due to the changing and swelling of the tendon’s structure.

PHT manifests itself as a deep pain in the glute. (literally a pain in the butt) .Pain is felt on or around the sitting bone(ischial tuberosity). Pain comes on gradually with no acute onset or mechanism of injury.

PHT is common in runners, but also occurs in the non-athletic population. Oftentimes people can have these symptoms for a long time, and they try to ignore it, until the stage where everyday activities are painful- sitting, going from sit to stand, stretching, sitting on hard surfaces.


How did I get this?

If you think you may be suffering from PHT you might ask why me? How did this happen?

Oftentimes a PHT develops after a period of increased training load. Have you increased your mileage, starting adding in hill workouts, more speedwork? All of these disrupt the balance in the tendon, not allowing the tendon enough time to respond and adapt, causing the tendon to become irritable and sore.

Similarly movements which put a compressive load on the hamstring tendon can cause symptoms. Excessive Yoga and pilates stretching positions which involve deep lunging can aggravate the tendon.


What do I do?

If you think this sounds like you book in with your physiotherapist for a thorough assessment. There are differential diagnoses which need to be out-ruled such a low back pain, stress fracture of the hip or an SIJ problem.

Keep on top of your pain. NSAIDS (anti-inflammatories) have been seen to be effective in reducing tendon pain. Discuss this with your GP or pharmacist. These should not be taken as a means to mask symptoms while running, but rather if pain is limiting your everyday activities. Heat/Ice can also reduce  your pain, see which works for you.

Gentle isometrics- shown in the picture. These exercises stimulate the muscle, maintaining your strength and have been shown to reduce pain symptoms. Aim to do 5 reps of up to 45 second holds, so long as there is no increase in pain. You may feel some tension but not pain, and symptoms should reduce after the exercise.


What do I not do?

There are certain positions and activities to avoid, particularly when the tendon is irritable.


-Periods of prolonged sitting, get up and move about to avoid compression on tendon.

-Don’t stretch: allow it may feel like this is what your tendon wants, it is not what it needs. Stretching places further compressive load on the tendon

– Deep lunging/ squatting

-up-hill running

– Don’t ignore your symptoms


How long will it take?

The sooner you get assessed the sooner you can get on the road to recovery. Tendon healing and restoration of full strength can take between 3-6 months. Within this period you may have resumed your activity fully and may be completely symptom free.

Once the cause of the tendinopathy has been found, you can start working with your physiotherapist to address this, whether that be pre existing weaknesses, training load management or other areas in your day to day which have led to PHT.



Ellie Harnett, MISCP

Fatigue Markers in Sport

Following on with some of our most recent posts on training load and injury/illness as we prepare to welcome Mark Roe for our August Seminar “Minimising Injury Risk and Maximising Performance in the GAA”, we will look at fatigue as a useful marker to monitor the athletes that we work in day to day, especially within the team setting.

Management of fatigue is important in mediating adaption to training and ensuring the athlete is prepared for competition. These training responses can be both positive and negative, and helps both the Strength and Conditioning and Medical staff see how the athlete is responding to the training load prescribed.

Different times of the year, different objectives will always make these slightly open to interpretation of the support staff e.g. during a period of planned overreaching,

the support staff will expect to have changes in fatigue markers that may be negative. Fatigue can also give us a better ability to reduce the athletes’ susceptibility to nonfunctional over-reaching, injury, and illness, by picking up signs and symptoms of difficulties to the training load early.

An excellent recent systematic review in Sports Medicine highlighted the role of fatigue on injury rates and illness in athletes. Below I have outlined some of the main findings from the review on fatigue markers and injury within that paper.

Fatigue Markers and Injury

The review showed that only 9 studies investigated fatigue–injury relationships, seven of which used perceptual wellness scales.

  • In soccer players 3 studies showed greater daily hassles to be associated with increased injury, using the Hassles and Uplifts Scale (HUS) (Ivarsson et al., 2010; Ivarsson et al., 2013; Ivarsson et al., 2015)
  • Laux et al. (2015) further support the positive perceptual fatigue– injury relationship in their findings, which reported that increased fatigue and disturbed breaks, as well as decreased sleep-quality ratings, were related to increased injury.

However, In contrast rating of perceptual fatigue showed slightly different findings in other studies:

  • Killen et al. (2010) found increased perceptual fatigue (measured via worse ratings of perceptual sleep, food, energy, mood, and stress) was associated with decreased training injury during an elite rugby league preseason.
  • Similarly, King et al. (2010) showed increased perceptual fatigue (measured via various REST-Q factors) was associated with decreased sports performance training injuries and time-loss match injuries.

The authors theorise that these unexpected findings may be due to the fact that when players perceive themselves to be less fatigued they may train/play at higher intensities, increasing injury likelihood.

Most of the studies used wellness scales that take approximately 1–4 min to complete. These are extremely practical to administer to athletes and are quick and not too time consuming. The Rest-Q has been also well-validated within the literature.

The review also showed that current self-report measures fare better than their commonly used objective counterparts. In particular, subjective well-being typically worsened with an acute increase in training load and chronic training load, whereas subjective well-being demonstrated improvement when acute training load decreased. Using quick subjective questionnaires and “knowing” the athletes is vitally important. Earning the trust of the athlete and building a strong relationship over a period of time, is just as useful as any expensive monitoring system.

The authors also noted the poor investigation within the literature of the relationship between sleep and injury.

Sleep is a vital part of the body’s recovery process and has been well highlighted in recent times on it’s relationship to productivity, chronic pain and depression (Rosekind, (2010); Smith (2004); Tsuno (2005). The review showed that three studies assessed sleep–injury relationships via sleep quality ratings, with only Dennis et al. (2015) investigating objective measures of sleep quality and quantity in relation to injury. No significant differences in sleep duration and efficiency were reported between the week of injury and 2 weeks prior to injury.


While the number of studies is quiet limited in the review, evidence of the use in the team setting to monitor the role of fatigue on injuries is supported. However, anecdotally and from experience within the field the importance of speaking to people, building strong relationships and creating a supportive environment cannot be underestimated. An athlete who trusts your role and job in helping their performance and having their wellness as a priority will often speak to you sooner than any subjective or objective marker can pick up.

So while using these tools is of great importance, don’t forget the strength of building personal relationships with your athletes.

Thomas Divilly

  • Ivarsson A, Johnson U. Psychological factors as predictors of injuries among senior soccer players: a prospective study. J Sports Sci Med. 2010;9(2):347.
  • Ivarsson A, Johnson U, Podlog L. Psychological predictors of injury occurrence: a prospective investigation of professional Swedish soccer players. J Sport Rehabil. 2013;22(1):19–26. 93.
  • Ivarsson A, Johnson U, Lindwall M, et al. Psychosocial stress as a predictor of injury in elite junior soccer: a latent growth curve analysis. J Sci Med Sport. 2014;17(4):366–70
  • King D, Clark T, Kellmann M. Changes in stress and recovery as a result of participating in a premier rugby league representative competition. Int J Sports Sci Coach. 2010;5(2):223–37.
  • Kinchington M, Ball K, Naughton G. Reliability of an instrument to determine lower limb comfort in professional football. Open Access J Sports Med. 2010;1:77–85.
  • Kinchington M, Ball K, Naughton G. Monitoring of lower limb comfort and injury in elite football. J Sports Sci Med. 2010;9(4):652.
  • Killen NM, Gabbett TJ, Jenkins DG. Training loads and incidence of injury during the preseason in professional rugby league players. J Strength Cond Res. 2010;24(8):2079–84.
  • Laux P, Krumm B, Diers M, et al. Recovery-stress balance and injury risk in professional football players: a prospective study. J Sports Sci. 2015;33(20):2140–8.
  • Rosekind, Mark R., et al. “The cost of poor sleep: workplace productivity loss and associated costs.” Journal of Occupational and Environmental Medicine52.1 (2010): 91-98.
  • Smith, Michael T., and Jennifer A. Haythornthwaite. “How do sleep disturbance and chronic pain inter-relate? Insights from the longitudinal and cognitive-behavioral clinical trials literature.” Sleep medicine reviews 8.2 (2004): 119-132.
  • Tsuno, Norifumi, Alain Besset, and Karen Ritchie. “Sleep and depression.” The Journal of clinical psychiatry (2005).
  • Dennis J, Dawson B, Heasman J, et al. Sleep patterns and injury occurrence in elite Australian footballers. J Sci Med Sport. 2015;19(2):113–6.

When working with sports teams, you meet a mixture of people working within the management and administration of the club/county. As it is still firmly an amateur organisation, the clubs and counties still rely heavily on the volunteerism that has built the foundation of the GAA, and please God may this never change! These people have a mixture of skills and experiences that make the GAA so unique to our country and culture. Everyone has different backgrounds that make trying to mesh an amateur ethos and drive with the professional demands needed to compete at inter-county and club levels easier. And yes, not only are inter-county setups extremely professional, a lot of clubs are following closely. Managers and coaches are extremely ambitious nowadays and want to create the most professional setups in the country.
And so often Physiotherapists, Strength and Conditioning Coaches and other related professionals are greeted with a mixed reaction within different setups, depending on people’s past experiences. Some are lauded as essential and necessary for continued success on the pitch, while some are greeted with a mixture of suspicion at our role within the team. We have all been in that situation, when you meet a coach or manager who doesn’t understand what your skillset involves, what you can do to help a team succeed. Physiotherapists are seen as giving out “rubs” and S & C professionals are seen as “doing the gym”. And while these may have been our role historically, we have moved on well from this! We have greater skillsets than this and we can heavily influence both the welfare and performance of the athletes we come in contact with.
And so like any profession I believe we should justify our roles within these groups:
  • Are we addressing intrinsic/extrinsic factors that may influence injury risk?
  • Are we putting in injury prevention programmes that have been proven to reduce rate of injuries?
  • Do we use the most up to date methods of preparing our players for their performance demands?
  • Are we continually up-skilling and increasing our knowledge?
  • Are we educating the people who make the important decisions on best practices?
These are all questions that we should be continually asking ourselves when working in these environments. So how do we justify our role first and foremost? What is the one thing every coach and manager puts the most weight on when making decisions? What can they not ignore. They are all striving for the same thing.
And while talent is important.
We know that team success is heavily influenced by player availability.
In this study by Hagglund et al. (2013) they looked at the injury incidence and injury burden on performance measures in soccer. What made this study unique is that the clubs that participated included the likes of Barcelona, Manchester Utd etc. So massive clubs at the elite level! And over an 11 year period they found that a team that had both decreased injury rates and injury severity compared with the preceding season had a statistically better chance of improved team performance, based on final league standing and league points per match. This is massively important!
The study concluded that the “association between injuries and performance is probably one of the most important messages to convey to management and coaching staff, as well as to other stakeholders in clubs, in order to continue to improve medical services for the players and to increase efforts to prevent injuries”.
Therefore, while we can’t prevent every injury, there is no magic bullet! We can use the best of our knowledge and our understanding of the science out there, how to put in programmes to help reduce the injury risk.
Read the data out there. Collect your own data. React to the data if needed.
Put into place some high quality injury reduction programmes.
Work as a team within the medical and performance department.
Help each other. Don’t let egos clash.
You should have a common goal. Work together to make it happen.
Thomas Divilly
Chartered Physiotherapist, MISCP, CSCS

As we gear up to present our next speaker Mark Roe, who will speak on training loads and injuries, we will begin to explore the role of training load on both athletic performance and injury reduction.

Training load is currently the hot topic within Sports Medicine and Sports Performance. But what is it? Training loads can be broken up into both internal or external variables. Internal training loads are the biological stressors imposed on the athlete during training or competition, these are commonly measured by heart rate, blood lactate, rating of perceived exertion etc. External training loads are objective measures of the amount of work completed during training or competition and common measures include GPS parameters. 

The importance of monitoring training loads has come to prominence over the past few years as its role in enhancing athletic performance and injury reduction has come to light through research. Traditionally the model to stress response imposed on the biological system has been based on the General Adaptation System Model proposed by Hans Selye in 1931. As John Kiely outlined in his article “Periodization Paradigms in the 21st Century: Evidence-Led or Tradition-Driven”, the periodization philosophy of training hinges on the presumption that biological adaptation to future training is largely predictable and follows a determinable pattern. However, we know that individual athletes will respond differently to each other even when doing the same training program/session. Biological stressors are often neglected as just training stress alone, however it comes in many different forms. For example, a wide range of imposed stressors emotional, dietary,social, sleep, academic have been demonstrated to variously down regulate the immune system, dampen adaptive response, and negatively affect motor coordination, cognitive performance, mood, metabolism, and hormonal health, consequently reducing performance and elevating injury risk. These all add up, and both the sports medicine professional or coach needs to be aware of these factors. Therefore, the ability to monitor the training loads of athletes, both internal and external, and their individual response is vitally important to enhance performance and prevent injury.

Thomas Divilly
Chartered Physiotherapist, MISCP, CSCS

Mind Over Matter: A Positive Mindset Can Help You Heal Faster from Running Injuries

Suffering an injury is a double blow for many runners: to their body and to their ego. Recovering from an injury is both a physical and a mental process and, in many ways, a positive mindset can help the body heal faster. Although many people do not accept the fact that the way we visualise the healing process matters,

many doctors and physiotherapists agree that there is a strong relationship between the way athletes approach their recovery process from a mental point of view and the duration of the recovery.

Mind Over Matter-A Positive Mindset Can Help You Heal Faster from Running Injuries

In this article, we will be trying to teach you how to build a positive mindset and confront an injury in a realistic manner with a clear outlook on the future. We believe that most of the post-injury harm mostly comes from within, from negative thinking, bleak perspectives and scenarios built in the runner’s mind.


These are a few helpful tips to help you stay optimistic and heal faster:


  1. Stop Looking Back and Making Comparisons

As you are taking your first steps after surgery or after the removal of the cast, you are tempted to remember the days before your injury, when you were running effortlessly for miles. Stop making this kind of comparison, stop it right now! This will only lead to wallowing in self-pity and never getting back to your former level of fitness.


Even if the gravity of your injury will diminish your athletic performance, you are not a defeated person. You are still a survivor, a strong person who can make the most of the circumstances you have to face. However, given the advancements of medicine, you are most likely to recover completely and be able once again to run effortlessly for miles. For now, focus on the first post-injury steps and learn to build strength and endurance again.


  1. Learn Everything You Can about Your Injury

Ignorance is the source of our deepest fears. Not knowing what kind of injury you suffer from can make you create the worst case scenarios in your mind. With so many sources of reliable information online (and your own doctor who will be more than willing to explain), you should find out everything there is to know about your injury: how long it takes until it heals, what type of rehabilitation therapy you need to follow, how long until you are ready to go back to your regular training. Having this information and a clear timeline until recovery, you can focus on positive thoughts and planning for your comeback on the running track.


  1. Give Yourself a Pep Talk

As you move on from complete rest to physical therapy, keep encouraging yourself with small speeches and reaffirmation statements. Remind yourself that you are strong and you will get over this injury. Find motivation in every milestone you achieve in your therapy and keep telling yourself that you can and will succeed to overcome this injury and get back to your usual performance level. This daily pep talk will work wonders for your mindset and your motivation to push yourself forward, and it will help you stay on track with your physical therapy.


  1. Set Yourself Achievable Goals

If you want to keep a positive outlook on your recovery, you need to determine a list of milestones which you can actually achieve. Setting unrealistic goals for your recovery means setting yourself up for failure, disappointment and even depression. Serious injuries take time to recover and your muscles need time to regain their strength and flexibility.

Trying to push yourself too hard with extenuating exercises and training may even cause you to suffer another injury or reactivate the existing one.

This will mean more time away from training and a longer time to recover, sometimes incompletely.


The best way of healing your injury is to remind yourself that this is just another hurdle which you will get over. Keeping a positive mindset is just as important as benefitting from professional medical treatment for your running injury.


Getting Back to Your Running Routine After Injury

Injury is an unavoidable aspect of physical exercise – for both amateurs and professionals. Some injuries are easier, while others will keep you away from exercising for weeks. Whichever the case may be, always wait until you get the green light from your doctor to start training again.

Since every injury is different, every training plan to return to your previous performance is different.

The factors which affect your training plan are:

How severe your injury was,

How long you had to rest your injured leg (not walking or putting pressure on it),

How fit you were before the injury, and

What type of physical therapy you were allowed to do during the recovery process.

The key to successfully getting back in shape is moderation. Many athletes feel pressured to get back to their level of fitness and performance as soon as possible, and set up an unrealistic training plan. For the purposes of this article, we will use the case study of a runner who had to spend eight weeks recovering from a serious leg injury.


1. The First Week of Training


Before you consider running, you should be able to walk at a brisk pace without pain and without getting tired for about half an hour without a break. Therefore, your first type of training should be walking.

Your initial walks should not exceed 1-2 miles on alternating days (maximum four walks per week). Allow your leg and foot to regain mobility naturally by progressively increasing the pace and briskness of your walk.


2. Weeks 2-5


By the second week, you should be able to walk up to four miles on alternating days. At this point, you will be able to keep up a brisk pace and, by the start of the 3rd week of recovery training, you should be able to do the first light jogs.

Jogging should not exceed 10 minutes during the 3rd week, with a 5-minute walking break in the middle. Allow your muscles to cool down with a brisk walk and then focus on resistance training through brisk walking.

During the 4th and 5th weeks, your jogging sessions should increase to 15 minutes per day, four days per week. Two days should be taken up by 3-mile walking combined with cross training or using the elliptical stationary bike for 30 minutes, and one day you will rest and focus on light mobility exercises.


3. Weeks 6-8


During this period you will focus on rebuilding muscle strength and resistance with intensive jogging sessions of 20-25 minutes four days per week, and walking and cross training two days per week.

The elliptical stationary bike will also help you build flexibility and strength (which is why you should include it in your cross training routine starting with the 4th week of recovery).
By the end of the 8th week, you should have regained your former level of strength and resistance. As you can see, the recovery training will take as much time as you spent recovering from the injury itself. While this is not a fixed rule, the main take-away from this article should be this one: getting back to your typical running routine is not achieved overnight and you should not try to push yourself too hard. You may risk reactivating your injury and make matters even worse.

Check out our recommended products to help you recover.


Five Tips So You Can Avoid Injury

Sports Physio Ireland’s physiotherapist Riain Casey talks us through five tips so you can avoid injury.

Many injuries can be easily prevented. Some times small adjustments to our everyday lifestyle can have a big impact in injury prevention.

Simple things like correctly fuelling the body and a good healthy sleeping pattern are key to aiding the body recover from on-field activity. Coupled with a specific warm up to prep the body for the demands on field, good proper movement based training and maintaining fitness levels to meet the demands of the activity can greatly help reduce the risk of injury or re-injury.

Try out the tips and let us know how you get on.

The importance of hip extension.


Many long distance runners fail to recognise the importance of good strength and conditioning training as part of their programmes. Running is very much a ‘catabolic’ activity, meaning that you can lose muscle mass during your training.

From an injury prevention point of view, it is extremely important to complement your running with good strength work to counteract this decline in muscle mass and reduce your risk of developing injuries such as shin splints, calf strains, or low back pain.

This does not mean lifting massively heavy weights in the gym that you have no interest in. Shown in the vid is a resisted step up exercise for running mechanics and the development of hip extension and glute strength. Give it a try.

Riain Casey MISCP

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