Posterior Thigh Pain Part 4 - Management of tendon pain and injury

Unless you recognise the source of your posterior thigh pain, your recovery can be drawn out and suboptimal.
Ashleigh Flanagan
February 26, 2022

One of the most common presentations I see is posterior thigh pain. However, depending on the source of symptoms, the management of posterior thigh pain, especially in the early stages, can be very different. While there are just a handful of common reasons for pain in this area, they can occur concurrently, or the mechanism behind the symptoms can change over time, making management tricky.

Rehabilitation is required to resolve most posterior thigh pain and extended rest is never best, but unless you (and your health professional) recognise the source of your symptoms, recovery can be drawn out. It's not uncommon for me to meet clients that have posterior thigh pain that limits their training for YEARS. It honestly shouldn't be this way. In general, posterior thigh pain is very 'treatable'.

The first post in this series briefly outlined the most common reasons for posterior thigh pain. Read the blog here.

The second post considered management of muscular posterior thigh pain. Read the blog here.

This last post discussed the management of nerve pain. Read the blog here.

Posterior Thigh Pain Part 4 - Management of Tendon Pain or Injury

How do I know if a tendon injury is the source of my pain?

All tendon injuries are overload injuries and are usually the result of doing too much too soon, often after doing not enough for too long. They tend to occur when starting a new training regime or increasing training load. However, injury risk increases not just with increased loading but also with reduced tissue capacity. This means stress, poor sleep, inadequate nutrition/hydration, previous injuries, lack of recovery between training sessions, incomplete rehabilitation, and illness are all risk factors.

Tendon injuries can be both acute and chronic. You will notice that a history of tendonosis increases the risk of tendon tear or rupture. Similarly, inadequate recovery from training and acute tendon injury can lead to tendonosis. Despite the link, its essential to recognise the difference between an acute tendon injury (tear/ rupture) and tendonosis because management is very different.

Management of an acute tendon injury

A tendon rupture or high-grade injury is usually apparent. You may feel a ping or hear a crack. You have difficulty walking and activating your hamstring. You may see a balling of the muscle. There will be bruising and swelling over time. It is time to make PEACE in the short term.

P- PROTECT- Avoid aggravating movements. If you can't walk normally, this means you should be using crutches until you can. It's also appropriate to rest until an appropriate health professional can evaluate you to minimise the risk of making the injury worse.

E- ELEVATION- Rest your leg up when you can to assist circulation and minimise swelling. This will also help with pain.

A- AVOID ANTI-INFLAMMATORIES & ICE- Inflammation and blood flow is vital for tissue healing, so taking anti-inflammatories will delay recovery in the short term. Ice may reduce blood flow to the affected area.

C- COMPRESSION- Compression can help reduce swelling, manage pain and improve circulation. 

E- EDUCATION- An appropriate health care professional should be able to talk you through a path to resolution that includes;

-Managing pain and symptoms in the short term,

-Things you can do to optimise your recovery,

-Things that may put you at risk of further injury or poor recovery,

-Surgical vs conservative options,

-What rehabilitation will look like for you, 

-The anticipated outcome of the process, & 

-An estimated timeline-based upon your unique situation.

Management of a chronic tendon overload/ overuse injury

If your tendon pain came upon your slowly or there was no acute incident resulting in a pop/ snap/ crack, bruising, swelling and loss of function, it's unlikely your tendon pain is due to a new tear/rupture. Instead, tendonosis, the thickening, stiffening and weakening of tendon over time associated with pain and inflammation, is a product of doing too much too soon with inadequate recovery. Tendons are designed to manage large forces, and heavy loading is excellent for tendon health, but programming needs to allow adequate recovery for tissue to adapt to demand.

Unlike acute tendon injuries, rest can worsen chronic tendon overload/overuse injuries and delay recovery. While there is symptom relief if you avoid aggravating activities, pain inevitably returns when you begin to reload. If we consider that part of the reason these injuries occur is that our tendons aren't robust enough to tolerate the load we have been asking them to, it makes sense. After an extended break from training, tendons are even less prepared to handle load.

Chronic tendon injuries need LOVE.

L- LOAD- All tissues heal through movement and loading. While it is ok to rest for a short period, no one recovers fully without loading. There is evidence that heavy loading and eccentric loading of tendons (muscle contracts as it lengthens) is the most effective way of rehabilitating chronic tendon overload, even if loading is painful.

O-OPTIMISM- High levels of worry and concern about an injury increase pain sensitivity. People are more likely to adopt behaviours that reduce healing, such as avoiding movement, socially isolating, and abusing alcohol and other drugs. Focusing on abilities, recognising progress and developing a plan to minimise symptoms whilst training will encourage a positive outlook. Adaptive coping strategies such as healthy pain management (heat, walking, gentle stretching, massage), prioritising self-care, managing stress, spending time with friends and family, and doing pleasurable activities will help promote optimism.

V- VASCULARISATION- General movement that increases the heart rate and blood flow to the injured area will reduce sensitivity, increase tissue healing, is great for general health, and can help people feel more positive about their situation.

E- EXERCISE- Movement, in general, is great, but training is even better. Studies have shown that planned and purposeful movement conveys more positive benefits than the same amount of incidental activity. While rehabilitation is necessary for chronic tendon injuries, the sooner a person can return to their previous activities with modifications, the better. This may mean returning to the gym at 75% load or stretching to ¾ intensity.

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