Avoiding the Pain, Rest, Weakness Downward Spiral

Proximal Hamstring Tendinopathy: Avoiding the Pain-Rest-Weakness Downward Spiral


Welcome to another episode of our podcast series dedicated to helping you overcome the challenges of proximal hamstring tendinopathy. In this episode, we will dive into a crucial concept known as the “pain-rest-weakness downward spiral.” We’ll explore how this concept can affect your recovery and discuss strategies to break this cycle. I’m Brodie Sharp, an online physiotherapist and a fellow proximal hamstring tendinopathy battler, and I’m here to guide you through this journey.

Understanding the Pain-Rest-Weakness Downward Spiral

The pain-rest-weakness downward spiral is a concept that plays a significant role in the management of proximal hamstring tendinopathy. It’s a cycle that many individuals with various injuries, not just hamstring tendinopathy, often find themselves trapped in.

Pete’s Story

Let’s start by illustrating this concept with a story. Meet Pete, an injury-prone individual who recently experienced knee pain. He had been running about 24-25 kilometers regularly but started developing pain around the 20-kilometer mark due to increased stress and reduced sleep from a new promotion. Concerned about his injury, he decided to rest completely for a week, which initially provided relief.

However, during his next long run, the pain returned at the 12-kilometer mark. Pete stopped running and walked home, thinking that he just needed a few more days of rest. After another week of rest, Pete cautiously attempted another shorter run. But on his third try, the symptoms flared up again, causing alarm. He booked an appointment with his physio.

The Spiral Unveiled

When a structure, such as the hamstring tendon, becomes irritated, its capacity to tolerate load decreases, making it temporarily weaker. However, complete rest can lead to further weakening. This is the essence of the pain-rest-weakness downward spiral. It’s a cycle where irritation leads to weakness, which, in turn, results in more irritation.

The longer this cycle persists, the more challenging it becomes to climb back up. You may have encountered this cycle in other tendon-related conditions like plantar fasciitis or Achilles tendinopathy. It can progress to a point where even daily activities cause irritation.

Avoiding the Downward Spiral

The key to managing proximal hamstring tendinopathy is to avoid falling into this spiral. Here are some essential strategies to help you stay on the path to recovery:

1. Gradual Progression

When returning to your regular activities, adopt a gradual and conservative approach. If your injury is irritated, start with low-intensity and short-duration exercises. Monitor your symptoms and gradually increase the intensity and duration as tolerated.

2. Isometric Loading

Isometric exercises can be beneficial in strengthening the affected tendon. For example, for Achilles tendinopathy, you can perform heel raises off the edge of a step, holding the position for 15-20 seconds. This helps the tendon adapt to load, reducing symptoms during and after physical activities.

3. Maintain Activity

Avoid complete rest, as it can contribute to further weakening. Even if you have to take a break from your main activity, like running, find alternative ways to maintain your tendon’s capacity through walking, cross-training, or specific strengthening exercises.

4. Be Proactive

Don’t retreat from activities at the first sign of irritation. Continuously retreating can lead to decreased tolerance for those activities. Be proactive in maintaining your capacity and gradually returning to your regular routines.


Understanding and breaking the pain-rest-weakness downward spiral is vital for the effective management of proximal hamstring tendinopathy. It’s about maintaining capacity, being proactive, and gradually building strength while avoiding complete rest. By applying these principles, you can pave the way to a pain-free and empowering future.

If you’ve found value in this episode, consider sharing it with others who may benefit from this knowledge. Remember, knowledge is power, and together, we can overcome proximal hamstring tendinopathy.

Stay tuned for more insightful episodes as we continue this journey towards recovery.