A Differential Diagnosis: My Journey to find Cause of and Treatment for Running-Related High Hamstring Injury

I am a female runner with left deep buttocks and thigh pain, the result of a running-related high hamstring injury. My quest (or differential diagnosis, as I feel like one of the young doctors on “House,” trying to glean a patient’s diagnosis from bits of history, a plethora of tests and trial and error treatment) to find the accurate diagnosis of the cause of the injury was the genesis for this article.

My running history is unremarkable. During my late twenties and early thirties, I ran thirty to fifty miles a week. I ran in local half marathons and 10-k races. I was the “rabbit” for friends training for marathons. I ran for the pure joy of the sport without much thought to cross-training, hydration or nutrition.

During the next almost twenty-five years, my running was sporadic. I might run consistently for a year, then life would interfere and I’d only hit the pavement at the Thanksgiving Day charity run. I remained active, however, by bicycling, hiking, walking (or trekking on family vacations) and swimming. 

I vicariously remained involved with the sport, encouraging my sons’ participation in cross-country and track. I cheered when Alex finished his first half marathon, winning his age division and a lovely handcrafted giraffe. My husband and I watched Christopher as he finished his marathon debut in the magnificent Olympic Stadium in Athens, soaking wet from the rain, a bright smile on his face.

Through the years, I missed the friendships forged while running, the delight of loping along forested trails, the chill as I pierced the morning dawn before work feeling the miles under my feet. My sons encouraged me to try again, so in January 2009, I started jogging the one-mile hilly loop of my neighborhood. My body adapted within a few weeks, albeit slowly, as I found a rhythm after my almost ten-year running hiatus. I completed a local 10-k race in May, coming first in my age group (there was clearly no competition). I was inspired to set my sights on a longer goal: I registered for the July 2009 San Francisco Half Marathon, and began training in earnest.

We had typical summer San Francisco weather during the race: cold, damp and foggy. The grids on the Golden Gate Bridge were slippery. The famed sunrise over the East Bay Hills was lost in the dark clouds. The hills seemed steeper than when we walked to and from the bridge. Despite the impediments, I completed the race just under my projected time. As I described the details later that day to my older son, he nonchalantly inquired about running a marathon.

My only attempt at a marathon had been interrupted by the pregnancy of that same son who now motivated me. The opportunity to revive this almost forgotten goal was enticing. I didn’t presume that success would come easily at my age (then 58) or with my time constraints. I could think of many excuses, but I realized quickly how much I wanted to try. With little fanfare (and keeping the goal secret from all but the closest friends and family), I registered for the December 2009 California International Marathon.

CIM is perfect for an inaugural marathon. The course directors would enthusiastically concur. The course is a fast point-to-point, net-downhill marathon. The weather is generally good. And, as an added bonus, the start is just miles from my house.

I had four months from registration to race day to train. I focused on steadily increasing my mileage, guided by an online training program. I had negligible time left for cross-training or core stability and strength exercises. In hindsight, this was the most glaring hole in my training; I didn’t listen to what I clearly knew about endurance sports.

Race day was cold, 31 degrees at the start, only warming to the mid-forties amid threatening skies and wind at the finish. I worried about fuel. I worried about the weather. I doubted my stated goal of finishing under four hours.

Despite my anxieties, I ran as planned, without undue effort, until the dreaded mile 21; my left knee and ankle started to buckle and wobble, torqueing in opposite directions. I struggled, stopping several times, until I realized I might not have the strength in that leg to continue. I coaxed myself (having fallen behind the pace group) with the mantra “You have to do this. You may not have another chance. This may be your only marathon.” The definition of “prescience” immediately comes to mind.

I forced my legs to work together as I neared the finish line banners. Somehow, I crossed the tape in 3:49:34, sufficient to attain the lauded “BQ” status and to qualify for New York. I was pale and stiff, tired and cold; yet, I couldn’t wait to run again!

That afternoon, I noticed a bright red streak from my inner left ankle to the mid-calf as if a child had taken a thick marker pen to the area where my ankle and knee decided to go their separate ways. It disappeared but remained a mystery. None of my healthcare providers seemed to take much notice of it.

Within six weeks, I was running six to eight miles several times a week. My legs felt heavy, but I figured I was still in recovery mode. Undeterred, I ran the Austin Half Marathon on Valentine’s Day, placing third in my age group (a PR of 1:50.03). I had some pain in the left buttocks, but with my son watching (having already finished the run), I sprinted the last quarter mile around the Texas capitol building to the finish line. Another mistake: sprinting, like intervals, can accelerate hamstring injuries.

I thought about my next goals. I had missed too many years of running during my prime years to be of masters caliber; however, if I trained with a coach, focused on intervals, hill repeats, endurance, core strength and flexibility exercises, all those things I should have done the previous fall, I wondered if I might be competitive at local or regional events. This was clearly magical thinking.

In anticipation of a coach-led running class, I practiced a few 4×200 intervals. One evening, only a few strides into the first interval, my left thigh was squeezed with a sharp, vise-like pain. I broke down in tears, as much from the pain as from the disappointment. I instinctively knew something was very wrong; I needed a professional opinion.

            In March 2010, I presented to a sports medicine specialist at an academic medical center. I described my running history and the pain, six or seven on a ten-point scale. Not debilitating, as I could walk, but not much else.

I had several range of motion and strength tests, but nothing to detect any biomechanical or structural deficits. Based on my unproven differential diagnosis, the failure to note hip or pelvic issues was a critical factor in my slow recovery efforts.

MRI results showed “normal pelvic MRI. No evidence of fracture, bursitis or hamstring injury.” The diagnosis of “proximal hamstring strain” related to overuse from running was vague.

I started a course of physical therapy, two times a week for ten weeks, consisting of exercises focused on strengthening the gluts and stretching the hamstrings. The circulation in the injured area was massaged to try to reduce any inflammation. Once the stabbing pain subsided, the physical therapist focused on soft-tissue mobilization using the Graston technique. A butter-knife shaped stainless-steel tool is rubbed along the thigh to break up adhesions and scar tissue and increase blood flow. I’m not sure it helped as I felt like a carrot being peeled!

I diligently performed my exercises and tried to rest the injured area. I iced the deep buttocks and thigh area, elevated my legs and swallowed untold milligrams of ibuprofen. Over time, I slowly added light indoor spinning and lap swimming to my regimen.

The intense pain in the deep buttocks area lessened over the ensuing months. My physical therapist released me to start using the treadmill to build to a walk/jog combination, preliminary to running. Unfortunately, the impact from even this light jogging impact retriggered the hamstring pain. My constant sitting in front of a computer at work (in a non-ergonomic desk/chair situation) ensured persistent pressure on the strained hamstring. My lifestyle was crosswise with my rehabilitation efforts.

The ramifications of my injury grew out of portion to the initial trauma. I could not safely contemplate running across the street if a car were coming. I could not comfortably sit at my desk or on an airplane. The psychological impact of the injury was insidious, placing pallor over my daily life.  Before the injury I did not think twice about bicycling or swimming or hiking. Now, I contemplated a disability that would not only prevent me from engaging in activities that are vital to my physical and mental wellbeing but are also important cornerstones of my relationship with my husband.

I had a second MRI in anticipation of a corticosteroid shot to ease the pain. Once again, the results were inconclusive: “unremarkable lumbar spine” with normal alignment and only mild disc bulge at L5-S with no significant nerve impingement. I scratched another potential diagnosis from the list.

The corticosteroid shot was administered just above the hamstring attachment point. The pain eased sufficiently so that by the end of August, I was running five to six miles around the local dirt track at my pre-injury half marathon pace. I deliberately scaled the mileage slowly, incorporating stretches during the runs while continuing the glut and hamstring exercises. I did not want to repeat or aggravate my seemingly dormant injury. I even harbored thoughts about running the NYC Marathon in November.

 And then, Labor Day weekend arrived. I savored the early dawn, ready for a run. With the first stride, as soon as my left foot struck the ground, deep pains radiated down the hamstring as if it had been ripped from the attachment point. I was devastated. Nothing relieved this new, intense and severe pain, even a second corticosteroid shot.

It was now late October 2010, almost eleven months after CIM and seven months after the interrupted interval training. My recovery was stalled; another perspective seemed prudent.

This time, I presented at the UCSF Sports Medicine Clinic, which uses a multidisciplinary approach to assess injured athletes. The physician spent almost an hour reviewing my clinical and running history, the initial diagnosis and my current course of treatment and MRI results. He performed a number of biomechanical and structural tests, immediately noting pelvic instability and weakness.

His diagnosis was “hamstring chronic insertial tendinosis.” The physician said my localized pain was likely related to weak core debility, which activates the hamstring. Basically, my core was not strong enough to provide the proper alignment among the muscle groups that are triggered upon movement. I was caught in a vicious circle: any movement further irritated the hamstring, impeding recovery efforts, but movement was inherent in my daily life.

Was this the Eureka moment that I was desperately seeking? Until now, the hamstring injury was considered in a vacuum, without consideration of potential hip or pelvic issues. The priorities of the differential diagnosis were evolving. During this next phase, physical therapy focused on core and hip strengthening as well as hamstring and quadriceps stretching. We discussed improvement in eight to 12 weeks. My hopes for running the NYC Marathon were dashed; Boston in 2011 was looking less likely, too.

 My exercise list continued to grow, including hip and glut strengthening protocols (the “monster walk,” single-leg squats, hip adductor and hip abductor exercises, the “hip hike,” “clam shell” and “scorpion”) and a more robust core strength and flexibility program (crunches, plank, superman, lunges, bridge and “quadraped” exercises). The names of the exercises were almost as convoluted as what I required my body to do. I was overwhelmed with the regimen, but I was determined to do what was needed. I could not abide the constant pain or limited physical activities.

I consulted a chiropractor, who confirmed the posterior left hip rotation and pelvic rotation misalignment. He explained that my neck shifts in order to allow my body to walk forward in a straight line. The torque placed on the hamstring from this misalignment was apt to cause or perpetuate the injury.

I commenced three-times a week chiropractic treatment with the goal of structural improvement and integrity. After five months or so of manipulation, the needle-like pain in the hamstring attachment area diminished. The deep buttock pain also lessened.

I increased my deep tissue massage therapy sessions. The massage therapist also noted the misalignment of my left and right pelvic bones (as I lay on her table, the pointy bones made this very clear). She also commented that my left hip was much looser than the right (eventually this was added to the differential diagnosis in the form of weak external hip rotators). She focused on soft-tissue mobilization, at the hamstring attachment points. She slowly massaged the layers of muscle until reaching the innermost hamstring muscle, almost bone-like in its stiffness.

In early spring, I jogged a few hundred feet. A victory in some respects: I did not experience the sharp, stitch-like pain at the hamstring attachment point on the first step. The bad news: the pain had shifted to the left hip joint, sacrum and piriformis area. My doctor assured me that the shift in the pain’s location indicated improvement, which may be true; still, the pain persisted.

I was dismayed at my slow progress. Although my chiropractic sessions were reduced to once a week, a subsequent visit to the orthopedist was dispiriting. The left hamstring remained weak, the quads were tight and my single-leg squats were wobbly. My planks were great, though! I left the building deflated and discouraged. 

To add insult to injury (pun intended), the physician suggested I consult with a sports dietitian due to my low body weight. (I am 5’ 5 ½”, and, at the time, weighed about 107 pounds.) I likely had a calorie deficit during training, which may have impacted my endurance, strength and power. It can also affect recovery. My husband, who bicycles and runs (and whose focus on nutrition is legendary in our family), would confirm this part of my self-diagnosis.

I discussed my diet (not quite vegetarian) with the dietitian. She recommended steps to increase my caloric intake and to adjust my eating habits to ensure the appropriate combination of carbohydrates, protein and fat. I am fully away of the need to add specific nutrients and calories to my daily diet; unfortunately, my neuroticism (not quite anorexia) towards gaining weight counters the objective facts. I keep a daily log of food consumed and calories burned through exercise. I strive for the proper balance, but it is difficult as my aerobic exercise is limited due to the injury. So many running articles focus on using the sport to lose or maintain weight, but those were the least of my problems!

My current rehabilitation regimen is comprehensive; strengthen my external hip rotator muscles and hamstrings; stretch the hip flexors; increase core flexibility and strength. In parallel, I continue massage therapy for soft-tissue mobilization and eccentric muscle lengthening; chiropractic treatment to maintain the structural alignment; Pilates to supplement the physical therapy; and swimming, bicycling, elliptical training and walking for my sanity.

Some days, I believe that discipline, focus and willpower will prevail over the injury. That is, after all, how I was able to complete the marathon. Other days, I doubt a full recovery. My last successful run was on February 14, 2010. My qualifying period expired for the Boston Marathon. I did not roll over my registration for this November’s NYC Marathon.  I cannot fathom, today, running 26.2 miles, as I cannot yet run a quarter mile.

At this point in time, my differential diagnosis confirms the high hamstring running-related injury. I strongly believe, though, that the physical assessment should have focused on why the hamstring overuse became so debilitating (and not merely due to the high mileage requirements of training for and running a marathon).  My weak external hip rotators and pelvic misalignment magnified the hamstring overuse. The pelvic torque and weak muscles stressed the hamstring whether I was walking, bicycling, swimming, running or sitting for extended periods of time. I may have further damaged the hamstring when I started running again after the first corticosteroid shot, resetting the time to recovery.

I have learned several important lessons from this journey: the accurate etiology of an injury is critical before rehabilitation can be truly effective; and hamstring injuries are very painful and heal slowly.

I chide myself for not being a better advocate. I should have questioned more at the outset, but I didn’t know what to ask. This is the third and possibly most important lesson learned over the course of the past almost year and a half. It applies not only to running injuries but also to one’s overall health. We ultimately are responsible for ourselves, no matter how many doctors, therapists or friends we consult. We must take this role seriously.

For all the analyses and diagnoses, the simple truth is that I miss the freedom, the joy, the solitude and the beauty of running in the Sierra Nevada foothills. I miss the all-out tiredness at the end of a long run. Even though my recent stint at running was limited in duration, it filled every fiber of my being. My heart aches as I slowly forget how the lightness feels, how the miles slip by on a Saturday morning run, how the joy permeates my daily life. How will I fill the hole if I am required to forego this beloved activity?