Hann-strings

I write this entry in the most comfortable position as of late- laying on my belly. My crutches are in reach, and the 8 cm scars stemming from both hamstring origins are free from pressure. How did I get to this point? It’s been quite a journey, and I’m not one hundred percent certain as to where it began. It may have started with a minor hamstring strain back in the fall of 2017. Or the glute cramping (or so it seemed)  during my training in summer 2018. Anyways, I will start with the symptoms I had, what types of treatments I tried  and continue on with where I was with my running when I figured out I was injured. 

Symptoms of my injury: 

-Upper hamstring pain

-Deep glute pain

-Pain on and to the inside of ischial tuberosity 

-Pain and discomfort was on both sides, and felt like it “switched” from side to side and to surrounding areas at times. 

-I could not sit for more than ~10 minutes (depending on surface)  without sit-bone area pain and a feeling of cramping in the surrounding areas. Car rides were especially bad! 

 – Injury symptoms started on left side and then became persistent on both sides

-Was able to use ellipitcal machine with no incline without reproducing symptoms 

-As soon as I began walking too fast/uphill or running, the pain and discomfort came on quickly

-Doing a back plank and raising my legs always reproduced the pain 

Injuries that present similar symptoms To Hamstring Syndrome or High Hamstring Tendinopathy: SI Joint Dysfunction, Piriformis Syndrome, Strained/Torn Glute muscles, Deep Gluteal Syndrome, SI Stress Fractures, Ichial Stress Fractures, Posterior Labral Tear, Ischial Bursitis (+more!)

*The Hamstring attaches at the sit-bone area. This is why it can be hard to differentiate between hamstring origin injuries and other issues in the posterior chain.*

(2015). Retrieved from https://orthoinfo.aaos.org/en/diseases–conditions/hamstring-muscle-injuries

Treatments Tried Before Considering Surgery:

-Initial PT focusing on pelvic stabilization, hip mobility and hamstring exercises (took some rest from running, incorporated pain free xtraining later)- hamstring exercises were Nordic curls, dead lifts with weights, bridge extensions using ball, isometric bridge – PT lasted 14 weeks 

-Dry needling of upper  hamstring and glutes 

-ART massage 

-Deep tissue massage

 -Theragun 

-Use of Normatec  legs regularly 

-No attempt at running for several months(did pain free cross training) 

-Two months without using my legs to exercise at all (arm bike only, swimming with buoy between legs)

-New bout of PT focusing on core, hamstring exercises with different loading phases (Loading Phases of hamstrings- isometric exercises, concentric/eccentric drills..)

-Cortisone shot to hamstring

-Cortisone shot to hip joint (to rule out labral tear)

-Extensive warm up before trying to run including glute activation drills 

-Two different running chiropractors to “realign” me 

-Pelvic floor therapy 

-Dry needling on pelvic floor muscles

Helpful Resources for Earlier Stages of HHT:

January-Mid March 2019: I was coming off of a solid training block at the end of January. I was in the best aerobic shape I’d ever been in. I almost PR’d in a half marathon (1:25) at the end of January after running 80 miles and a few workouts in the 6 days prior. I had several strong long runs of 16-20 miles in the 6:40s to 6:50 range. I felt that I was ready to have my best marathon in March. My husband, Martin, and I were planning to run a Marathon in Marseille on our honeymoon.

On my way to winning the Pettit Half Marathon. January, 2019.

I started feeling really uncomfortable and “stuck” during my runs toward late February. My stride was choppy now and I couldn’t figure out what was wrong. I thought I was just tired and my muscles were tight. I often got a cramped feeling in my glutes to accompany this feeling. This isn’t even what alarmed me the most initially.  I felt a sharp pain and pull from the inside of my left knee during a run. I now know that the hamstring tendon wraps around at this point and the sciatic nerve runs through this area. It was so painful that I couldn’t run even if I tried. I took several days of just biking and the knee pain went away, though the area still felt a bit “locked”. I still felt that same discomfort throughout my posterior chain as well. I have never had an injury come on like this so I was confused. After all, it was only discomfort..not excruciating pain. I hadn’t dealt with many injuries, but when I had they were obvious to me and didn’t require more than a few modified days or weeks typically. I thought, “I could still have a good marathon, I could still be okay. I just need to loosen up my muscles.” We made it to the start line, but did not finish the race. I remember feeling really uncomfortable at mile 3. We made it through mile 13 or 14. I just could not continue. I felt stuck and stiff and had a horrible “cramped” feeling in my left glute. It was so frustrating because I felt great aerobically. I was right at the front of the women race and knew I could win! My husband shared in my frustration and sadness… it was a long walk back to the hotel. I was so confused. I didn’t have excruciating pain, why did I have to stop? I kept thinking back, was it just mental? What happened to me? I told myself I was just stiff from the long plane ride and maybe this was all in my head. I was so mad at myself. I started to notice more discomfort and pain (in the sit bone region) throughout the trip. I tried to forgive myself and convince myself that I wouldn’t have just stopped for no good reason. I knew there was something wrong with me.

Before the Marseille Marathon. March, 2019.

April- July: I worked with PT who specializes in running. She was very thorough and sincerely wanted to help me. The diagnoses I was given was SI joint dysfunction. I do not blame her for not catching the hamstring issue. The symptoms are very similar and it’s hard to know for sure without imaging. I took several weeks completely off of running and then started up very slowly.  After about 5 weeks of PT I wasn’t seeing the slightest bit of improvement so I reached out to a PT friend of mine for an (now third) opinion. He mentioned High Hamstring Tendinopathy (HHT). I started doing the exercises he gave me in conjunction with the others. I added in some light workouts and even did a few races (though not all out and nothing over 5 miles). The symptoms were so on-and -off.  I was often confused and doubted myself. I felt much better some days then others. As I got closer to July and built up to about 65% of my previous mileage, I knew something just wasn’t working. It took me so long to recover from my runs. I would previously do a 10-12 mile workout in the morning and an easy or even tempo 4 miles on some days. Now, if I ran a 5-6 mile tempo run, my body was so stiff the next day that I could barely move. I felt like my torso wasn’t connected to my legs. There was a constant cramping and down-pulling feeling by my lower glute area on both sides.  It was such an odd feeling. I had to stop and stretch or take a break during runs. I had several mental breakdowns during runs (shout out to Martin for dealing with that on too many runs together!) I was constantly researching my symptoms to find was might be causing them and if it was something different that SIJ Dysfunction or HHT. Nothing I was doing was working. I knew this wasn’t right. I had been doing HHT and stabilization exercises for months with no positive changes. The relief felt with these things was very minor. Towards the end of July I gave up on running completely.  I was mentally exhausted.

August: Throughout the summer, it was getting increasingly difficult to sit comfortably. I delivered for Amazon Flex in addition to teaching summer school. I was so uncomfortable all of the time. The pain and cramping came on after 10-20 minutes of driving. I tried getting a special seat cushion, I tried making a cushion myself with golf balls in the front to take the pressure off of the upper hamstrings and glute area. I finally got an MRI which revealed a partial thickness tear on the insertion of my left hamstring as well as swelling and edema at that site. It also revealed a torn labrum. The doctor said the symptoms could be coming from both findings. We needed to do more to find out. 

September: The doctor injected me with cortisone first on my hip, and then my hamstrings. I felt a small amount of relief with the injections, but the feeling went away after a few days. We wanted to do more investigating into what was causing the symptoms. At this point I was not working out with my legs whatsoever. I took August, September and part of October (about 10 weeks) only using the arm-bike or swimming only with my arms, using a buoy between my legs. 

October : We did an MRI of the right side (as this side had similar-though not as intense) symptoms. The thought was that if the right side showed one of the injuries that was the same as the left we would find the cause of pain. The MRI showed a labral tear. The doctor ruled out the hamstring as a major cause of pain. I was referred to a hip-specialist. The hip specialist wasn’t convinced that the labral tears were causing pain. MRIs can show false positives of labral tears. He said my findings were unclear. Many people have asymptomatic labral tears as well-unfortunately there is not enough research to know exactly why. My symptoms, mainly in the glute area, were not indicative of most labral tears. I was more confused than ever. To completely rule out the labral tear as a cause of pain, the doctor gave me a lidocaine injection in both hip joints. I was to run 5 or so minutes before the injection and 5-8 minutes after. If I felt “like a miracle” occurred than this could confirm that the pain was coming from the labral tears. I felt no difference whatsoever. I followed-up with the doctor. He seemed very confused as to what the injury was. He said I probably was just very tight in my glutes and upper hamstrings. He recommended that I go to a new PT for at least another 4-6 weeks and then we’d discuss other options such as Platelet-Rich-Plasma (PRP) injections  in the glutes or hamstrings. He seemed annoyed by my questions and seemed to think I wasn’t truly injured. I remember leaving the doctor with Martin and tears just started flowing from my eyes. I was so frustrated. I was even more confused than I was back at the end of July. I got my hopes up to find an answer so many times only to be let down and written off. I felt like the doctors didn’t believe me and I was doubting myself at this point.

November: I completed another bout of PT along with pelvic floor therapy (5-6 weeks total).  I was doing HHT loading exercises along with my PT exercises. The PT was not originally going to include exercises for HHT issues, but I was convinced that this injury involved the hamstrings. I had all of the symptoms of HHT and there was a partial tear in the  origin area shown on the MRI. What else could it be? I knew I wasn’t just “tight!” The exercises were giving me no relief or even the slightest bit of improvement. I didn’t know what else to do. There was only one more thing I could think to try: reach out to a leading experts in HHT. There are not many doctors who are experienced in this in the U.S. and there is not a lot of research on the topic.  I reached out to a physiotherapist in Washington who works with runners who have HHT. He evaluated my MRI report and symptoms and told me that the injury was HHT related. He didn’t know what else to try, other than more PT, since I did almost everything he would recommend (with the exception of PRP injections). I read much of what was out there. I spent a lot of time sifting through research and comparing it with my symptoms and the treatments I’ve tried.  A bulk of helpful information came from Dr. Orva and Dr. Lempainen (Neo Hospital in Turku, Finland). I figured I might as well try to reach out to one of them and ask for advice. Both doctors have spent a majority of their careers dealing with athletes who have hamstring injuries and conducting research on the topic. I didn’t have anything to lose. I sent Dr. Lempainen my MRI images and a history of my running and symptoms. I knew that he would be able to tell me the best protocol to follow if the issue did in fact involve the hamstrings.  I told myself that I would follow whatever he told me IF he got back to me. 

Martin’s Madison Marathon Win. November, 2019.

Early December: I heard back from Dr. Lempainen. He told me I had large tears at two insertional points of my left hamstring as well as hamstring syndrome (this is when HHT has become chronic, lots of scar tissue build-up) and it is definitely the cause of my symptoms. He told me that there was quite typical hamstring syndrome on the right side (pre-tear condition, though no tear). The sciatic nerve on the right and left sides were entrapped by scar tissue. This is why I was so uncomfortable just sitting down (the nerve is compressed when sitting). I was informed that the left side would need operation for sure. There was no way I would get back to running, or sitting for more than a few minutes pain-free without operation. No amount of PT or PRP would help; in fact, the PRP would cause more scarring and further exasperate my symptoms. Dr. Lempainen was thorough in answering my questions and explaining the reasoning for the surgical technique to be used. I felt relief that I had an answer from him and that he was so sure. There is just one catch: the surgery I would need is not available to me in the U.S.

Surgical Technique and Planning the Trip: Dr. Lempainen uses a different technique and the rehab time is 2-3 times faster than procedures offered in the U.S. More about the technique is found here: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3667353/.  The doctors in the U.S. are much less experienced with this injury and surgical technique . I did my research and couldn’t find many places that would even attempt this. Most surgeries call for cutting off the tendon completely and reattaching it.  The success rates were unfavorable as well. I talked to a professional runner who had the procedure done by Lempainen. She was so helpful in answering my questions and spoke very highly of her experience. Lempainen is highly experienced, focusing his career (nearly 20 years) on hamstring injuries and performing thousands of surgeries. He also focusing on treating athletes specifically. Still, I didn’t know if we could afford the flights or if insurance would cover an overseas procedure. Fortunately, my insurance covered the procedure. We were able to pay for the trip as Martin had just one the Madison Marathon. We used some of the prize money towards the trip. He received his check the exact day we decided to pursue the surgery. He was behind this endeavor one hundred percent. I booked the flight and was incredibly nervous. I had free 24 hour cancellation and it was really a blessing when the time passed. No turning back- I had to be all in at this point! I am so thankful for my parents, Martin, and a few close friends for helping me through this decision. Besides the logical reasons, I had such an intuitive feeling telling me to go to Finland and get the surgery. It seemed “crazy,”  but I knew I had to do it. This type of injury also gets more complicated to fix surgically as more time passes. I considered giving up running and dealing with day-to-day pain. As I said considered this aloud through tears, I knew it was against what I truly wanted. I wanted to give this surgery a shot so that I could feel good again and maybe run again (maybe fast!) one day. So many things that I love I wouldn’t be able to do because of this injury. I knew I would regret it if I didn’t try. 

The first part of our trip Dec 15-Dec 18: After four flights, We made it to Turku, Finland early on December 17. We slept in late, had a great breakfast and then worked out together in the fitness room. We spent a lot of the day resting as we were tired! The next day the morning looked similar. In the late morning, we walked to Neo Hospital. I had a series of MRIs with special hamstring sequences. I met with Dr. Lempainen later that afternoon. I was so nervous that he would tell me something completely different. I was used to seeing doctors and hearing the uncertainty in their voices and leaving feeling hopeless and frustrated. After I met with him I felt so relieved. The MRIs showed greater tearing than we initially thought- two tendons on the left side were almost ripped completely off the bone. The left and right sides also showed diseased tissue (or scar tissue build-up) as well as sciatic nerve entrapment and edema. He was sure of the type of surgical technique to be used to give me optimal healing. He knew that surgery was the best option for both sides and was thorough in his explanations. I then met with Jari Hemling, a physiotherapist who works closely with Dr. Lempainen. He gave me sets of exercises to start one week post operation (PO) all the way up through eight weeks, and I did a set of all of them to make sure I was doing them correctly. He, along with Lempainen, are working with my PT back at home to make sure every one is on the same page with the rehab process. I felt like I was in good hands. 

Hospital Neo. Turku, Finland

The Day of Surgery, December 19: Martin and I woke up early the day of surgery and worked out together. I enjoyed my last bit of being active before the surgery. We then walked to the hospital together. It was 8:00 when we left and still pitch black outside. At this time in Finland the daylight lasts about 5 hours (10am-3pm). After getting my surgery outfit on, I was rolled out to the operating room. I laid on my belly with my eyes shut, and said a last prayer. I listened to the nurses and doctors speak in Finnish, and then received a spinal anesthetic and a sedative. A little over three hours later, I woke up from surgery. I was laying on my back. My legs and feet were numb. I remember wanting to see Martin. I was given some water, and not long after I needed to go to the bathroom. At this point it was a couple hours after surgery. I was given food as well though it wasn’t appetizing to me at all. I had some fruit, and ate the pickle off my sandwich and just waited. Dr. Lempainen came in by me and told me it was a successful surgery. He explained to me exactly what he did. On the left side, the tendon was reattached to the bone with two anchors and the sciatic nerve was freed. On the right side the tendon was elongated and the sciatic nerve was freed.  Another hour or so passed and Martin was able to come in by me. I was so happy to see him. After the numbing wore off I was wheeled by the nurses to the bathroom (although sitting is prohibited for a month after surgery, it was okay in very small amounts with a special cushion and legs extended). I felt shaky getting into the wheelchair. As we got to the bathroom, I slowly stood up. I woke up a few minutes later with hot face, laying down in the hospital bed. I had fainted. I didn’t try to go to the bathroom again for several more hours. I was given an IV pump with sugars during this time. I was given pain meds as well which made me feel very sick. We tried to get me in the wheelchair again and I fainted for the second time. Finally, around 12 hours after the surgery I just barely made it to the bathroom and back without fainting. We waited another short time and then a handicap taxi took us back to the hotel. I was able to walk with crutches for very short distances. I made it about 15-20 seconds of walking and then collapsed on the hotel couch. We waited a while and finally made it to our room. I remember feeling like the room was miles away. I was so relieved to make it there. I laid down for several hours and then tried to go the bathroom again. This was a 10 step walk. I made it about 3 steps before collapsing on Martin. The fainting happened several more times throughout the night. After vomiting several times when waking up from fainting I didn’t want to try to get up at all until later the next morning.

Image may contain: Hannah Erl, smiling, indoor

A few minutes before the fainting spells commenced.

Martin chomping on trail mix a few hours after surgery.

My first steps out of the handicap taxi. Night of surgery- December 19.


The five days Post-Operation Dec 20-24:I was relieved to make it without fainting next time I got up. Martin got me some breakfast and brought it up to the room. I didn’t feel like eating, but I tried some of it. The doctors told me it was important to eat enough sugar and salt to raise my blood pressure. I felt much better a few hours after eating. I rested most of the next few days and was finally able to walk to the bathroom without Martin. Walking down to the hotel lobby seemed like a big feat. After three days we rode in a cab to check-in with Dr. Lempainen and get new bandages. I was nervous about flying the next day. The first flight went okay- we didn’t have to move much at all from the place we were dropped off. The staff were so accommodating and the flight was short-only 50 minutes. They lifted me into the plane as I couldn’t walk up the steps. I was able to lay across seats on the flight as well. When we arrived in Stockholm we were wheeled to a couch by our boarding area where we would stay for 4 hours. The next flight was 4 hours long. It was very crowded and hot in the plane. I alternated between standing and leaning on my lower back  with cushions underneath me and feet out in front of me. It is difficult to travel in a cramped plane when you are not able to sit. The flight felt much longer than it was. I was nervous for our 10 hour flight the next day. We had a layover in Madrid that night. It was nice to be able to take a break from flying. We were dropped off at our terminal the next morning. We needed to get to gate S. To my horror, the sign in front of me said “28 minute walk to gate S.” The staff at the airport were not helpful in accommodating me to get to the gate. Martin was directed elsewhere several times before we knew we weren’t getting any help. Several kind strangers helped us make the journey. I had to alternate between walking VERY slowly and “sitting” on the wheelchair, propped up so my legs were straightened and the incisions weren’t pressured. It took us almost an hour and a half to get to our gate. Martin was so patient all the while, carrying two backpacks and pushing two suitcases (after getting his 8 mile run in early in the morning!). The staff on this plane were much more accommodating than the last. I was so grateful for them. They allowed me to lay on my belly across four seats. I was comfortable and relieved. I didn’t care about the 10 hours- I was glad to be in a good position to protect the incision sites! We finally arrived in Chicago at 2:20pm on December 24. My parents picked us up and I laid in the back of the car for the 90 minute drive home. Martin and I were so relieved to be home. We went over to my mom’s house later that night for a short time to celebrate Christmas with our family. The next day Martin and I watched Christmas movies and then went to my Aunt’s house to be with family again. It was a unique Christmas, but I felt grateful to be around my family, I felt extremely loved, and I felt optimistic about recovering from my injury. 

Dr. Lempainen and me at the 3 day post-op check up.

A unique, but wonderful Christmas.

Lessons from this experience:

*Listen to your body and don’t doubt yourself- you know your body better than anyone else!

*If some medical professionals cannot help you or are not willing to try, don’t stop until you find someone who can. 

*If you are not getting answers from others, seek to find them for yourself, even if it seems impossible.

*Don’t give up on the things you really want, only to regret it down the road.

*Take care of yourself, be patient, and give yourself grace when you are filled with uncertainty about something. Find someone to vent to about these things or write them down- it’s not helpful to keep them inside.

*When everything seems uncertain, keep a list of things you can control and do to help yourself. For me some of these things were: get enough rest, eat well, learn more about my injury, reach out to those who can help, do things that ease my stress and bring me joy.

*Have multiple things that support you mentally. I have relied on running a lot to keep calm and relieve me of anxiety. It’s important to have more than one thing you can focus on to keep you “sane.”

*Don’t take being active for granted-It is such a blessing to be healthy!

Blessings I was reminded of during this journey:

*My incredibly patient husband. He did so much for me including: Supporting me throughout the injury, listening  to me explain all of the research I found, being there for me after mental breakdowns and doubting myself over and over, accompanying me to frustrating doctors visits and keeping me optimistic afterwards, encouraging the decision to pursue this surgery, holding me up many times after I fainted, staying awake to make sure I was okay, resting with me, bringing me food, traveling with me through the airport carrying all of our luggage and setting up accommodations for me. There is much more that I haven’t listed. I am so grateful for Martin. 

*My supportive parents, friends and co-workers who listened to me when I needed to vent, showed understanding, and checked in on me to make sure I was okay.

*There are many things in life that bring me joy: friends, family, teaching, reading, baking, moving in other ways besides running, writing, and art. How wonderful to take a break and focus more intently on other things I love!

*The timing and provision we were given to make this journey to Finland possible. It fell together at the right time, and it certainly was not “luck.” 

*The chance to pursue this surgery at all, and the incredible doctors I worked with in Finland!

*The hope this surgery gives me to be active in a pain-free way again.

Additional Helpful Hamstring Injury Research:

  • Cacchio, A.; Borra, F.; Severini, G.; Foglia, A.; Musarra, F.; Taddio, N.; De Paulis, F., Reliability and validity of three pain provocation tests used for the diagnosis of chronic proximal hamstring tendinopathy. British Journal of Sports Medicine 2012, 46 (12), 883-887.
  • . Fredericson, M.; Moore, W.; Guillet, M.; Beaulieu, C., High hamstring tendinopathy in runners: Meeting the challanges of diagnosis, treatment, and rehabilitation. Physician and Sportsmedicine 2005, 33 (5), 32-43.
  • Lempainen, L., Surgical Treatment of Hamstring Injuries and Disorders – the Clinical Spectrum from Chronic Tendinopathy to Complete Rupture. Turun Yliopisto: Turku, 2009; p 66.
  •  Lempainen, L.; Sarimo, J.; Mattila, K.; Vaittinen, S.; Orava, S., Proximal Hamstring Tendinopathy: Results of Surgical Management and Histopathologic Findings. The American Journal of Sports Medicine 2009, 37 (4), 727-734.

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