from Giving the Glory
For the last four years I’ve struggled with chronic high-hamstring pain. After trying endless treatments with no avail, I finally came across a condition known as “hamstring syndrome;” a chronic form of high hamstring tendinopathy that occurs when scar tissue builds up, irritating the sciatic nerve and hamstring insertion. Now that I’m 8-weeks post-op from hamstring syndrome surgery, I wanted to share some insight on the condition and what ultimately led me to chose this operation.
My pain first started during my senior year of college back in March 2013. There wasn’t one particular workout where I keeled over, but after a hard speed session I noticed pain in my high hamstring, way up in the awkward spot known as the ischial tuberosity. I took a few days easy but since it was my last collegiate track season I decided to push through a great deal of pain, and was able to manage it with active release, graston, and chiropractic adjustments. By May of 2013 I could barely even run my warm-up before races, so I shut down my season after the USA Outdoor Track Championships. An MRI revealed “high hamstring tendinopathy” (HHT) but no visible tear. The following summer and fall I rested and began consistent physical therapy. This helped me get back to the starting line and run several lifetime bests in 2014, but eventually the exact same pain returned. Being the stubborn runner that I am, I once again pushed though months of pain leading up to USA’s. This time, however, the pain became much worse and forced me to quit high level training and racing.
Over the next two years it was a constant battle. Despite months of rest, slow build-ups back to training, physical therapy, massage, and chiropractic work, my pain never had any lasting improvement. I had multiple MRI’s, x-rays, bone scans, ultrasound, an EMG, and bloodwork; all of which provided no further diagnosis. I tried every treatment option under the sun, including rounds traditional PT with eccentric exercises, rounds of PRP and cortisone injections, pelvic floor therapy and trigger point injections, dry needling, active release, biomechanical analysis, shockwave therapy, and even had surgery to repair a labral tear on my hip, (the thought behind this was that my labral tear was causing instability in my hip, which had forced my hamstring to take on more stress and therefore was constantly being strained). Although that operation was successful at fixing my hip impingement (FAI), it did not resolve my gluteal/hamstring pain.
When my one of my physical therapists, Simon Gutierrez, first told me about “hamstring syndrome” I was intrigued. All of my symptoms matched perfectly: pain in the high hamstring that would radiate down the leg (the path of the sciatic nerve), pain and tightness throughout the glute muscles, pain running at fast paces, making sharp turns or quick changes in pace, pain that also increased with the duration of the run (I had to cut my mileage to less than half of normal because of this) pain sitting more than 20min, (particularly driving), and a long history of HHT that did not improve with traditional PT. Hamstring syndrome can be defined as “a gluteal sciatic pain, in which posttraumatic or congenital hard fibrotic bands irritate sciatic nerve at the insertion site of hamstring muscles to ischial tuberosity.” ¹( Basically, hamstring syndrome is when HHT becomes chronic to the point where scar tissue and adhesions build up along the tendon and tether it to the sciatic nerve, leading to chronic pain. ,
I decided to contact Sakari Orava, a Finnish surgeon who pioneered surgical management for hamstring syndrome back in the 1980’s, along with his colleague Lasse Lempainen at hospital NEO in Turku Finland. Being that they are two of the top sport surgeons in the world (Dr. Orava has previously operated on David Beckham and Haile Gebrselassie,) I trusted their input. I sent them several of my MRI’s and they noticed some oedema (inflammation) and a small tear in the hamstring tendon on one of my old MRI’s (just goes to show how radiologists sometimes miss things!). The tear was small enough that it healed on its own, but in the process large amounts of scar tissue built up over the years. Based on my symptoms, the length of time I’d been in pain, and having tried all other treatment options, they decided surgery was the best option.
The type of surgery performed by the doctors in Finland is very different from the type of surgery I was offered in the U.S.A. Most surgeons here are only trained to operate on partial or full-tears (avulsions) and these operations involve completely detaching the hamstring tendon and reattaching it with an anchor. Since my hamstring tendon attachment was fully intact, there was no point in causing even more damage, not to mention the recovery time from traditional hamstring surgery vs. hamstring “syndrome” surgery was the difference of 6-12 months of recovery vs. 8-10 weeks! There was also a major difference in cost; the cost of surgery in Finland was about 1/5th or less of what the operation would cost in the U.S.A. After doing all the research, and once I realized this may be my only hope at returning to competitive running, I decided to go for it and my husband and I booked our tickets to Turku, Finland.
When I arrived in Finland I met with Dr. Lempainen for a physical examination before I made my final decision on surgery. Based on several tests including the “Puranen-Orava” stretch test (seen below), he determined that I was indeed a good surgical candidate. My operation was performed the following day, 1/17/17. You can read more about the surgical technique in this article², but basically I was in prone position (lying on stomach) while they created a vertical incision from my ischial tuberosity down about 5″ (yeah it’s a pretty long scar, scroll down and see it if you dare!) I was awake the whole time, which was interesting, although under spinal anesthesia (obviously!) The technical terminology for the procedures performed were a fasciotomy, partial semimembranosus tenotomy, debridement, and sciatic nerve liberation. A lot of adhesions were found between my glute muscles, hamstring, and sciatic nerve. They also anchored my SM tendon to my biceps femoris muscle.
It was a fairly quick operation, (about an hour-and-a-half I believe) and I was able to leave the hospital that same day. The trickiest part was figuring out how to avoid sitting thereafter. Post-op protocol involved no sitting for the first 4-weeks as well as no active stretching. I had a fun time being wheeled out of the hospital on a stretcher and into a handicap taxi, (which felt more like an ambulance). The rest of my week in Finland I spent resting up in bed, but was able to use crutches, full-weight bearing, from day one. Overall, my stay at hospital NEO was top-notch. The doctors and nurses were very kind, and Dr. Lempainen and Dr. Orava were very welcoming, encouraging, and answered all of my questions about making a comeback from this surgery.
I flew home from Finland four days later. First-class made it easy to lay down, but travelling on crutches is never exactly fun! The following two weeks I stayed at home on the couch/bed, and was lucky to have my mom there to take care of me and drive me to PT appointments. The following weeks looked something like this:
- One Week Post-Op: Started gentle massage and micro-current therapy.
- Two Weeks: Off crutches and started some light quad strengthening exercises, core (mainly gentle transverse abdominis activation exercises), gentle leg swings, clams, and isometric glute activation. Cryotherapy treatments helped bring the swelling down.
- Three Weeks: Added standing arm bike to get my heart rate up and keep me from going crazy. Also got in the pool to do some light aqua jogging (just for range of motion, not cardio), along with swimming with my arms-only and a buoy between my legs.
- Four Weeks: Added in some very gentle stretching and nerve glides, along with some hip flexor strengthening and bridges. I finally was able to sit again!!! But I limited it to as little sitting as possible.
- Five Weeks: Was cleared to do 20-30min sessions on the elliptical and started sitting for longer periods.
- Six Weeks: Took my outdoor ElliptiGo bike for a ride to enjoy the glorious great outdoors.
- Seven Weeks: Continued to gradually increase my aqua-jog, swimming and elliptical minutes.
- Eight Weeks: Hoping to try Alter-G treadmill soon!
- The goal is to jog at the 10-week mark, but I’m taking it one week at a time and listening to my body 🙂
So you think you have hamstring syndrome?
I realize that a lot of readers out there are probably like me. You found this blog and you’re saying to yourself “Oh my gosh, this sounds just like my symptoms, I better get this surgery!” I know this because I’ve been there before, and I have received many comments on the blog I wrote about my last surgery. While I do recommend hamstring surgery for anyone who has dealt with chronic hamstring syndrome and has exhausted all other options, I am not a doctor and am not trying to diagnose/give medical advice here. There are a lot of other injuries that can cause similar pain. I suggest consulting with your doctor, and ruling out other conditions such as a lumbar disc injury, disc degeneration, piriformis syndrome, a full or partial hamstring tear, sports hernia, compartment syndrome, pelvic floor dysfunction, labral tear, hip impingement, neurological problem, stress fracture, etc. If you’re still in the early stages of HHT, I recommend this article.
If you are like me and have tried everything else, I’d be happy to share more info about my experience. The main reason I am writing this blog entry is to provide more info on hamstring syndrome since there are limited resources on the web from actual patients. Feel free to message me on my contact page or Facebook. This injury can be a real pain in the butt, so I feel for you all!
Okay, now for the fun part, pictures of the scar…
- This is a really helpful PDF that explains hamstring syndrome symptoms and treatment options including surgery: Hamstring syndrome – proximal tendinopathy. Sakari Orava Prof, MD, PhD. Turku
- For those who have high hamstring tendinopathy but aren’t at the surgical point, I recommend this article from Runners Connect. These are great exercises and treatment options to try: https://runnersconnect.net/running-injury-prevention/high-hamstring-tendinopathy-injuries-a-pain-in-the-butt/
- Great article by American physician Robert Gendler who had this surgery in Finland: http://www.hospitalneo.com/en/sivu/1235/physically_active_american_robert_gendler_finds_relief_for_hamstring_pain_at_hospital_neo
- Article describing difference in cost of surgery: Gendler, Robert “An American physician’s foray into Scandinavian healthcare” Scandinavian Journal of Public Health, 2016; 44: 225–227