Training Update: My PT Eval and a Tentative Plan

When I came home from a hilly 10 mile run on December 1st I knew my hamstring needed rest. I did a little research to try and identify the achy, tightness that resonated deep in my glute at the top of my hamstring and concluded that it might be high-hamstring tendonitis. At the time the thought of taking a week or more off from running seemed...well, seemed impossible. December 23rd marked three weeks with no running and I didn't die or go crazy, in fact I kind of >gasp< enjoyed it and according to the physical therapist who I saw that same day, it was possibly the best thing I could have done. The rest allowed my body to heal and also gave me the opportunity to focus on strength training. Rest and the addition of focused strength training are probably the two reasons why my physical therapy appointment had a happy ending: the go-ahead to run. During my appointment my physical therapist evaluated my hamstring and noted that I didn't have any significant inflammation, knotty build-up on the tendon or scar tissue that she could feel; probably due to the fact that I didn't engage in any activity (running) that would aggravate the hamstring tendon for three weeks. That alone gave me a leg up (pun intended) on recovering from hamstring tendonitis.

The area in red is the tendon of the hamstring.

But she did address the likely cause of the discomfort/tightness that I'd been feeling since August and that is an imbalance between the strength of my left hip and the strength of my right hip. My left hip is weaker, tending to stretch and elongate when I move. That weakness and elongation although subtle (and significantly improved from my first postpartum visit with her almost a year ago) is causing things to break down at high mileage and high speed. Muscles and tendons have to compensate for the imbalance and that undue stress causes injury. In my case and inflamed hamstring tendon.

The exercises she prescribed to address the weakness are very similar to those she assigned to me last year when I was working to correct pelvic floor weakness. Everything she assigned sounds simple, but honestly trying to "turn on" those weakened muscles takes a lot of concentration. I find myself closing my eyes as I try to isolate those little stabilizing muscles in my hips.

Knee to Chest: Laying on my back I brace my hips (pull up the pelvic floor, engage the psoas, keep the tailbone pressed towards the floor, and engage the deep rotators) and slowly bring the right knee to the chest while keeping all those little muscles "turned on." My main focus is keeping the hips stable. What tends to happen is that my left hip lifts and twists when I begin to move my right leg to my chest because the right side is stronger. The lifting and twisting of my hips is an incredibly subtle movement that you or I may not even notice. But the trained eye of a physical therapist picks up on these things and can prescribe strengthening exercises to help.This video is similar to the move that I am performing, however I have been doing it without the foam roller and when she cues "belly" what she's really talking about is lifting the pelvic floor and engaging the transverse abdominal muscles...basically bracing the hips as described above.

Clambshells: Laying on the side brace the hips in the same way as described above and slowly lift the knee. My range of motion on this one is pretty small, because the higher I try to "open" and lift that knee I quickly lose proper form and the hip "brace" breaks down and I start using all the wrong muscles. This video shows it relatively well and emphasizes the use of the "back pocket" muscle or the gluteus medius.

Adductor Squeeze with Leg Lift/Lower: Laying on my stomach place yoga block between thighs. Brace hips/lift pelvic floor as described above then squeeze a yoga block with inner thigh. Then flex at the knee to lift the foot. This one is hard because you want to initiate the lifting and lowering with the inner thigh vs. the major glute muscles. This video is the closest I could find to demonstrate the action. It shows the prone adductor squeeze and comments on proper hip placement, the difference is the addition of the knee bend which should be initiated by the inner thigh.

The most important thing to keep in mind during each of these exercises is the stability of the hip. In most cases I need to reduce the range of motion so that my hips remain stable. In some cases it can seem frustrated, especially to someone who considers themselves fit and "strong." I realized a while ago that opinion of myself really gets me know where. The truth is I'm pretty weak and imbalanced and if I want to be the strong, fit runner I think myself to be I've got to correct those imbalances.

One thing that my PT did note was that strength training and the PT exercises she prescribed will always need to be a part of my training program. If I want to run hard I have to continually invest time into building strength (make a deposit), that way when it comes time to run high mileage and high speed (make a withdrawal) my body can handle it and will not start to break down. Running without strength training is like withdrawing from your bank account without making any deposits: you'll eventually spend it all and wind up broke. And if you continue to run a weak and imbalanced body you'll wind up broke as well.

What Next?

The PT gave me two guidelines for returning to running: no incline and no speed. I've been running easy, although there is always the temptation after three weeks off to see what pace feels "hard" and try to gauge what fitness I lost, so avoiding speed work isn't the hard part. It's avoiding hills that will be a bit of a challenge because I live on the side of a hill. Either way I turn out of my house means an uphill at some point. I may be relegated to running on the treadmill in my basement or back and forth on a flat half-mile stretch near my house.

The other major caveat to returning to running is to take it easy and continue with strength training. With these guidelines in mind I've created a tentative plan for the next two weeks. Here's what it looks like:

Week 1 December 30-January 5

Monday: Easy 2-3 miles. PT Exercises.

Tuesday: 20 min strength session (Jillian Michael's Ripped in 30 or 30 Day Shred)

Wednesday: Easy four miles with running club. PT Exercises.

Thursday: 20 min strength session (Jillian Michael's Ripped in 30 or 30 Day Shred)

Friday: Easy 2-3 miles. PT Exercises.

Saturday: Easy 3-4 miles. PT Exercises.

Sunday: 20 min strength session (Jillian Michael's Ripped in 30 or 30 Day Shred)

Week 2 January 6th to 12

Monday: Easy 3-4 miles. PT Exercises

Tuesday: Easy 2 miles. 20 min strength session (Jillian Michael's Ripped in 30 or 30 Day Shred)

Wednesday: Easy 2-3 miles. PT Exercises (This will be the third day of three days in a row of running, it will be interesting to see if there is any tightness or discomfort in my hamstring and will be a good test to see if I can increase frequency of running in the coming weeks.)

Thursday: 20 min strength session (Jillian Michael's Ripped in 30 or 30 Day Shred)

Friday: Easy 3-4 miles. PT Exercises.

Saturday: Easy 4-6 miles. PT Exercises.

Sunday: 2 miles easy and 20 min strength session (Jillian Michael's Ripped in 30 or 30 Day Shred)

I think that resting early on proved to be the most effective thing I could have done and probably prevented further damage from happening and allowed any existing damage to the hamstring tendon to heal. If I feel any tightness or discomfort in my hamstring during these next two weeks I'll know to back off and go back to strengthening. The PT and strength sessions will remain part of my weekly routine. I know that if I don't make that commitment now I'll be injured again later on down the road.

I have two, two-mile runs under my belt so far: I ran on Tuesday and again on Christmas day. Both runs felt great, the pace was easy and comfortable (and I didn't lose as much fitness as I feared). Post run I've felt no discomfort or tightness, which leads me to believe I'm on the right track.

Disclaimer: I am not a licensed health professional or physical therapist. If you are suffering from a running injury you should consult your doctor of physical therapist to seek adequate treatment. The exercises suggested in this post are simply suggestions and should not be assumed to be treatment for an injury.

Have you ever taken a long time off from running? How did you come back? Do you have any guidelines for increasing frequency or intensity post injury?

--Sarah

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