By: Rachel Krentzman, PT, E-RYT
One of the most common complaints that I have encountered among yoga teachers and practitioners alike is an intense, aching pain in the bony area deep in the buttocks crease, also known as the ‘SITS” bones. It is usually painful to deep pressure or when sitting on a hard surface and tends to be exacerbated by forward bends (uttanasana and parsvottanasana) and deep lateral angle bends (virabhadrasana/warrior II and Utthita Parsvakonasana). Usually, these symptoms are due to a Hamstring Tendonitis, an inflammation around the attachment of the hamstring tendon to the pelvic bone. This little ache can eventually become a chronic and disabling condition if left untreated, but with the proper knowledge and alignment can be prevented and cured completely. Unfortunately, most athletes and yoga practitioners will tolerate the pain until it eventually becomes unbearable and does not allow them to continue their usual level of activity.
Strain vs. Tendonitis
How do you know if you are experiencing a hamstring tendonitis?
First, it is important to understand the difference between a Hamstring Strain and a Hamstring Tendonitis. A strain is defined as: a deformation of an object due to external loading. It is usually felt in the muscle belly, behind the thigh or knee and is usually most painful 2 days after intense physical activity after which point it gets progressively less painful. Treatment for a strain includes rest, gentle stretching and soft tissue work to break down scar tissue and to make sure the muscle does not heal in a shortened position.
A hamstring tendonitis is a repetitive stress injury.
It is an irritation and inflammatory process that occurs at the origin of the hamstring tendon. For some reason, the tendon (where muscle attaches to bone) is undergoing too much tension during the individual’s activity which causes it to be pulled away from the bony attachment. At a certain point, this stress becomes too much for the tendon to bear since it is only a small area in comparison to the huge hamstring muscle belly, and the inflammatory process sets in. This condition is usually treated with anti-inflammatory modalities such as ice, anti inflammatory medication, ultrasound etc. however, this approach is limiting since it only serves to treat the symptoms. Until the actual cause of this excessive tension on the tendon is uncovered and corrected, the problem will persist.
Anatomy and Physiology of your Hamstrings
The hamstrings muscle is made up of four parts; the Biceps Femoris (long and short head) and the Semimembranosus and Semitendinosis muscles. The long head of the biceps femoris originates at the ischial tuberosity and the sacrotuberous ligament, crosses the hip and knee joint and inserts into the head of fibula and lateral condyle of the tibia. Its function is to flex and laterally rotate the leg and extend and laterally the thigh. The short head originates at the lateral lip of the linea aspera of the femur and inserts into the head of the fibula and the lateral condyle of the tibia. It only crosses the knee joint and functions to flex and laterally rotate the leg.
The Semimembranosus originates in the ischial tuberosity and inserts into the medial tibial condyle. The Semitendinosus muscle also originates at the ischial tuberosity and inserts into the upper part of the medial surface of the tibia and medial tibial condyle. Both these muscles, extend the thigh and flex and medially rotate the leg.
Flexibilty vs. Stability
Most people believe that yoga is all about increasing flexibility and that the more flexible you are, the less susceptible to injury you will be. The truth is, sometimes being too flexible can increase your chances of sustaining an injury. Yoga is about achieving a balance between flexibility, strength and stability. In most cases, you have a genetic predisposition to being flexible which is a combination of mobility in your joints, laxity of your ligaments and the stiffness of your muscles.
So before you even step onto the mat, you have a certain amount of flexibility to work with, one that is beyond your control. Generally women have looser ligaments and more flexibility than men, while men tend to begin with more inherent stability and strength.
So often, I watch as yoga practitioners turn red and shake while trying to achieve a version of a certain pose exerting too much force than their muscles can bear. Overstretching the hamstrings is all too common. For example, in downward facing dog, if the hamstrings are tight, trying to straighten the knees too much will compromise the pose and decrease your potential to lengthen the spine which is one of the main benefits of the pose. In fact, if the low back is tight and the hamstrings are forced to stretch beyond their capacity, all the force will pull on the tendon at its attachment to the pelvis.
This is not saying that you cannot increase your flexibility. You can improve at any age. However, in order to effectively stretch your muscles so that they maintain a more flexible state, the stretch must be slow, controlled and sustained. Any kind of quick, harsh stretch will create a reflex and cause the muscle to contract and shorten up.
According to Shirley Sahrmann, PT author of Diagnosis and Treatment of Movement Impairment Syndromes, the ideal length of the hamstrings is achieved at 80 degrees of hip flexion. This may seem ‘very tight’ according to most yoga practitioners, however, there may be an emphasis on becoming too flexible in order to accomplish an ideal of what a posture ‘should’ look like. When you push too hard into a pose, the tension has to go somewhere and it is most likely going to pull at the musculotendinous junction. In addition, being too flexible in your hamstrings can contribute to instability in the pelvis and sacroiliac joints, contributing to back pain and/or sacroiliac joint dysfunction. This is especially true if there is an imbalance and the hip flexors, including the psoas major and rectus femoris muscles, are inflexible relative to the hamstrings.
Common faulty movement patterns
Another common cause of hamstring tendonitis is a combination of abnormal forces on the tendon due to a particular faulty pattern of movement. Figuring out the cause of this repetitive stress is the tricky part. Each individual is different and a proper diagnosis will include looking at the individual’s daily activities, body type, joint mobility, flexibility and strength. More importantly, it is crucial to observe the individual’s movement patterns, especially their alignment during their yoga practice and any other activities they may engage in.
Since we have seen that 3 out of 4 of the hamstring muscles originate at the ischial tuberosity, it is obvious that pelvic alignment plays a crucial role in the stresses placed on the hamstring tendon.
Hamstring Tendonitis and Asana
Common poses that increase pain/tension on the hamstring tendon include:
- forward bends
- downward facing dog
- reverse triangle
- warrior II
- extended side angle pose
Here are some tips to correct and avoid stress on the Hamstring Tendon:
- Redirect the Stretch! Main thing is that you want to feel the stretch in your muscle belly, not in the buttocks.
- Keep Pelvis Level
- Practice just below your edge
- Keep the thighs active
- Distract at the hip joint
- Bend the knees if needed
- Realize your genetic limitations, acceptance, patience
- Stretch your hip flexors!
- Listen to your body, pain is a sign that you have gone too far!