Proximal Hamstring Tendinopathy (PHT) is a painful overuse injury commonly affecting athletes who engage in sprinting, hurdling, jumping, or activities that involve repeated hip flexion. It manifests as deep buttock pain right at the “sit bones,” medically known as the ischial tuberosity, where the hamstring muscles attach to the pelvis.
Understanding PHT is critical because, if left untreated, it can lead to chronic pain, reduced athletic performance, and long-term disability. This comprehensive guide covers causes, risk factors, symptoms, and evidence-based treatments so you can manage PHT effectively and return to your sport or active lifestyle.
What Is Proximal Hamstring Tendinopathy?
The hamstrings are a group of three muscles that run from the pelvis to the lower leg, playing a key role in hip extension and knee flexion. Proximal Hamstring Tendinopathy refers specifically to injury and degeneration of the hamstring tendon where it inserts at the ischial tuberosity.
PHT is a type of insertional tendinopathy, where the tendon is repeatedly compressed and strained during movements involving hip flexion and adduction (e.g., lunges, sprints). This excessive load leads to micro-tears, inflammation, and pain at the tendon’s attachment point.
Typical complaints include:
- Deep buttock pain that worsens with prolonged sitting.
- Pain during or after running, especially sprinting.
- Discomfort when stretching the hamstring (e.g., forward bending).
- Weakness or stiffness in the affected leg.
Causes of Proximal Hamstring Tendinopathy
Several factors can contribute to the onset of PHT. Key causes include:
- Sudden increase in training load
- Rapidly increasing the volume, speed, or intensity of sprinting, hill running, or jumping puts excessive tensile and compressive stress on the hamstring tendon.
- Introducing new activities
- Starting activities like hurdles, lunges, or deep squats without adequate preparation can overload the tendon.
- Static stretching in extreme positions
- Prolonged, aggressive stretching (common in yoga or Pilates) places sustained compression on the tendon, leading to irritation over time.
- Prolonged sitting
- Sitting for long periods, especially on hard surfaces, increases compression on the tendon, aggravating symptoms.
- Muscle imbalances or weakness
- Weak gluteal muscles can increase the workload on the hamstrings, predisposing the tendon to overuse injuries.
Risk Factors for Proximal Hamstring Tendinopathy
In addition to mechanical causes, several risk factors can increase the likelihood of developing PHT:
- Age-related changes: Tendons lose elasticity and capacity to withstand load as we age, making PHT more common in middle-aged and older adults.
- Body composition: Higher body mass index (BMI) increases the stress placed on the hamstring tendons.
- Hormonal changes: Women, particularly those who are perimenopausal, may have an elevated risk due to reduced estrogen levels, which negatively impact tendon health.
- Metabolic conditions: Diabetes and other metabolic disorders can impair tendon healing.
- Medication side effects: Certain antibiotics (e.g., fluoroquinolones) and corticosteroids are linked with increased tendon vulnerability.
Diagnosing Proximal Hamstring Tendinopathy
Accurate diagnosis is key to successful rehabilitation. Diagnosis is based on:
- Clinical examination: Reproduction of pain with resisted knee flexion or hip extension in positions of hip flexion.
- Functional tests: Pain during single-leg deadlifts or forward lunges.
- Imaging: MRI or ultrasound may show tendon thickening or partial tearing in chronic cases.
Evidence-Based Treatment for Proximal Hamstring Tendinopathy
Progressive loading exercises are the gold standard for treating PHT. Strengthening the hamstring tendon gradually helps remodel the tissue and restore function.
Researchers recommend a four-stage rehabilitation program, progressing from pain-relieving isometrics to high-load, sport-specific exercises. This staged approach minimises the risk of re-injury and ensures a safe return to activities.
Stage 1: Isometric Exercises
Objective: Reduce pain and begin gentle loading of the tendon without compressing it.
- Exercises involve static contractions of the hamstrings with the hip in neutral or slight flexion (20–30 degrees), avoiding positions that cause discomfort.
Example exercises:
- Isometric leg curls: Press your heel into the floor or a resistance band while lying on your stomach, holding the contraction for 30–45 seconds.
- Bridge holds with minimal hip flexion.
These exercises can decrease pain through neuromodulation and improve tendon load tolerance.
Stage 2: Isotonic Exercises with Minimal Hip Flexion
Objective: Restore muscle strength using heavy slow resistance (HSR) training.
- Focus on both concentric and eccentric movements with slow, controlled repetitions. Start with higher reps and low resistance, progressing to lower reps with higher resistance.
Example exercises:
- Prone leg curls on a machine or with bands.
- Nordic hamstring curls: Slowly lower your body forward while keeping your hips neutral, engaging the hamstrings eccentrically.
HSR exercises have been shown to stimulate collagen remodeling, which is vital for tendon healing.
Stage 3: Isotonic Exercises in Increased Hip Flexion
Objective: Transition to functional, sport-specific strength by introducing hip flexion angles of 70–90 degrees.
- Begin once the patient tolerates lunges or other hip-flexion-based load tests without sharp pain.
Example exercises:
- Walking lunges.
- Romanian deadlifts.
- Single-leg “diver” (single-leg deadlift with balance challenge).
These exercises mimic athletic positions, helping prepare the tendon for return to dynamic movements.
Stage 4: Energy Storage and Release Exercises
Objective: Restore elastic and explosive function for activities like sprinting, jumping, or cutting manoeuvres.
- Introduce plyometric or ballistic exercises every third day, as they pose the highest load on the tendon.
Example exercises:
- Kettlebell swings.
- Alternate-leg split squats or split jumps.
- Bounding drills.
This final phase is essential for athletes aiming to return to high-impact sports.
Key Principles for Successful PHT Rehabilitation
- Monitor pain levels carefully: Mild discomfort during exercises is expected, but pain should not worsen after 24 hours. Persistent or worsening pain suggests the need to reduce intensity or modify exercises.
- Gradual progression: Rushing into advanced exercises can lead to setbacks. Progress through stages only when pain during daily activities and functional tests is minimal.
- Single-leg training: Asymmetrical strength loss is common in PHT. Prioritize unilateral exercises to correct imbalances.
- Address contributing factors: Strengthen the glutes, core, and other supporting muscles. Modify activities to reduce excessive sitting or stretching during recovery.
- Seek professional guidance: Work with a qualified physiotherapist experienced in tendinopathy rehabilitation to tailor the program to your individual needs.
Tips for Preventing Proximal Hamstring Tendinopathy
- Warm up properly before activities involving explosive hip extension.
- Gradually increase training loads—avoid sudden spikes in intensity or volume.
- Strengthen hamstrings and glutes year-round to build resilience.
- Incorporate eccentric hamstring exercises like Nordic curls into your routine.
- Limit prolonged static stretching or sitting when experiencing symptoms.
When to See a Physiotherapist
If you experience persistent deep buttock pain, pain with running or sitting, or weakness in the hamstrings, consult a physiotherapist or sports medicine professional. Early intervention with a structured rehab program can dramatically reduce recovery time and improve outcomes.
Proximal Hamstring Tendinopathy can be a challenging and frustrating condition for athletes and active individuals alike. However, with a thorough understanding of its causes, risk factors, and a staged rehabilitation approach, most people can recover fully and return to their sport or activity without lingering pain.
Remember: strengthening, not just stretching, is the key to happy, healthy hamstrings.
