Slow heavy resistance training: A 2020 case study

Brodie discusses a 2020 cade study paper by Kayla Krueger, Nicholas Washmuth & Tyler Williams titled: “THE MANAGEMENT OF PROXIMAL HAMSTRING TENDINOPATHY IN A COMPETITIVE POWERLIFTER WITH HEAVY SLOW RESISTANCE TRAINING” We dive into the case of this 31-year-old male competitive powerlifter that had failed prior treatments including static and dynamic hamstring stretching, hamstring soft tissue mobilization, dry-needling, general hamstring strengthening exercises, tenotomy and PRP injections. Listen to hear the details of the strength protocol that produced significant benefits within 4 weeks and continued to see results 12 months after his 12-week program.  Click here to learn more about the PHT video course & to receive your 50% discount If you would like to learn more about having Brodie on your rehab team go to  Or book a free 20-min physio chat here

Title: Proximal Hamstring Tendinopathy: A Case Study on Slow Heavy Resistance Training

Subtitle: Overcoming Buttock Pain When Sitting


In this podcast episode transcript, we delve into the world of proximal hamstring tendinopathy (PHT) and explore a 2020 case study that sheds light on an innovative approach to managing this condition. Proximal hamstring tendinopathy, also known as high hamstring tendinopathy, is a debilitating condition that often plagues athletes and individuals who experience buttock pain when sitting or discomfort in their bottom area. We will examine a unique rehabilitation method known as slow heavy resistance training and its effectiveness in treating PHT.

Understanding Proximal Hamstring Tendinopathy

Subheading: The Nature of PHT

Proximal hamstring tendinopathy is a chronic overuse condition resulting from repetitive mechanical loading of the proximal hamstring tendon. Commonly diagnosed in athletes, especially middle and long-distance runners, and those who engage in activities such as squatting, lunging, stair climbing, and sitting for extended periods, PHT can be excruciatingly painful.

Subheading: Conventional Treatment Approaches

Traditional treatment strategies for PHT predominantly focus on conservative methods, avoiding surgery, and emphasizing progressive tendon loading within a pain management framework. However, not all patients respond positively to these interventions, with up to 45% of Achilles tendinopathy patients failing to improve with eccentric exercises alone. This raises questions about the efficacy of eccentric-only exercises in managing tendinopathy.

Heavy Slow Resistance Training: A New Approach

Subheading: Introducing Heavy Slow Resistance Training

One innovative approach that has emerged in the treatment of PHT is heavy slow resistance training. This method combines both concentric and eccentric phases, prolonging the time under tension experienced by the tendon compared to eccentric exercises alone. The key focus here is on performing slow, fatiguing, progressive exercises that encompass both concentric and eccentric components, thereby promoting greater tendon adaptation.

Subheading: The Purpose of the Case Study

This podcast episode explores a 2020 case report titled “The Management of Proximal Hamstring Tendinopathy in a Competitive Power Lifter with Heavy Slow Resistance Training.” The study aims to shed light on the effectiveness of heavy slow resistance training for PHT, using a competitive powerlifter as the subject. While the case study focuses on a powerlifter, its findings offer valuable lessons for anyone recovering from PHT.

The Case Study: Subject History and Treatment

Subheading: Subject Description

The subject of this case study was a 31-year-old male competitive powerlifter who had been diagnosed with left PHT. Prior to seeking recent treatment, he had undergone various interventions, including static and dynamic hamstring stretching, soft tissue mobilization, dry needling, general hamstring strengthening exercises, and eccentric exercises. Despite these efforts, he did not experience significant improvement and eventually discontinued physical therapy.

Subheading: The Primary Complaint

The subject’s primary complaint was pain that exacerbated during activities requiring hip flexion while maintaining a neutral spine, such as deadlifting and squatting. He also experienced discomfort with prolonged sitting and driving, which had a negative impact on his job and daily life.

The Intervention: Slow Heavy Resistance Training

Subheading: Designing the Rehabilitation Program

The subject embarked on a 12-week independent rehabilitation program centered around heavy slow resistance training. During each of the three weekly sessions, he selected two bilateral exercises and one unilateral exercise from a list that included various deadlift variations, squats, hip thrusts, and hamstring curls. Each repetition of these exercises involved a three-second concentric and three-second eccentric phase, totaling six seconds per rep. The subject initially aimed for a rate of perceived exertion (RPE) of 7, later progressing to 9 as he adapted to the protocol. It was important that pain during the exercise was acceptable but did not worsen after the session.

Subheading: Monitoring and Follow-up

Regular follow-up conversations with the therapist involved monitoring program compliance, collecting data on pain levels, assessing sitting tolerance, and evaluating weightlifting tolerance. Despite the subject’s preference for home-based exercises, follow-up was conducted through phone calls and emails.

The Outcome: Success with Heavy Slow Resistance Training

Subheading: Positive Results

Following the 12-week heavy slow resistance training program, the subject showed significant functional improvement and was able to return to competitive powerlifting with minimal pain. Notably, he no longer experienced aggravating pain during prolonged sitting and driving.

Subheading: Early Signs of Improvement

Crucially, within just four weeks of starting the program, the subject reported a meaningful decrease in pain, which motivated him to maintain compliance throughout the 12-week duration. This early improvement set the stage for his successful rehabilitation journey.

Key Takeaways

Subheading: Lessons from the Case Study

After analyzing this case study, several key takeaways emerge:

  1. Tendons Love Slow, Heavy Load: Tendons respond well to slow, heavy resistance training, making it an effective strategy for rehabilitation.
  2. Progression is Key: Ensure that your exercise program includes progressive overload to continue challenging and strengthening the tendon.
  3. Balance Bilateral and Unilateral Exercises: Incorporating both double leg and single leg exercises can provide a comprehensive approach to rehab.
  4. Pain During Exercise is Acceptable: Pain during exercise is acceptable, even encouraged, as long as it does not worsen post-exercise.
  5. Expect Meaningful Change in 4-6 Weeks: If you don’t see improvements within this timeframe, consider modifying your rehabilitation plan to enhance outcomes.


Proximal hamstring tendinopathy can be a debilitating condition, but this case study highlights the potential of heavy slow resistance training as an effective rehabilitation method. By understanding the principles of this approach and incorporating progressive, well-balanced exercises, individuals dealing with PHT can find relief and regain their active lifestyles. Remember, tendons love slow, heavy load, and meaningful improvements can be achieved within a few weeks with the right approach. Don’t let PHT hold you back—take control of your rehabilitation journey today.