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Hip Pain

Proximal Hamstring Tendinopathy

Minute Read


Posted 2 months ago


by James McCormack

Hamstring tendonitis is a widely known painful condition involving the hamstring attachment to the bone. It is more accurately called hamstring tendinopathy. Tendinopathy can occur at both ends of the hamstring muscle, where it attaches to the bone. At the lower end, the attachment is below the knee and is called distal or low hamstring tendinopathy.

In this article, we will discuss the causes, symptoms, diagnosis and treatment of proximal hamstring tendinopathy, which affects the upper attachment of the hamstring to the seat bone, the ischial tuberosity. 

Proximal Hamstring Tendinopathy Symptoms

The most common symptom is pain on the seat bone, sometimes described as just on the inside of the seat bone. This may also feel like stiffness, tightness or fatigue in this area.

The whole hamstring may feel tight, but usually, the seat bone will be the point where the most tightness is felt when stretching.

Symptoms are aggravated by compressive or sheering forces at the ischial tuberosity. This includes sitting, especially if on a hard surface, high angles of hip flexion,  sprinting, running up hills and stretching the hamstring.

Proximal Hamstring Tendinopathy Treatment

In most cases, treatment with a specific rehabilitation exercise programme will be effective and successful to reduce pain and strengthen the hamstring tendon. So long as aggravating activities are modified, reduced or stopped.

Nonsteroidal anti-inflammatory medication can also play a role in symptom relief but should not be used in the very early, acute phase as they can stop the positive effects that inflammation has on healing (Su & O’Connor, 2013).

If rehabilitation exercises are not effective or there is time pressure on recovery then additional treatment can be used, such as extracorporeal shockwave therapy. In a very small number of cases, steroid injections can be used. Caution must be taken with steroid injections as they can have a negative impact on tendon tissue health.

All of these additional treatments will not be effective on their own, all need to be used along with a comprehensive and specific strengthening programme for the hamstrings and surrounding muscles. 

Exercises for Proximal Hamstring Tendinopathy

Exercises for hamstring tendinopathy will depend on your specific case. Generally speaking, early rehabilitation will start with strengthening the hamstring with concentric and eccentric exercises with the hip in a neutral position to avoid compression of the hamstring tendon against the ischial tuberosity. As strength improves, symptoms reduce and the hamstring is able to tolerate more, the exercises will be progressed to higher resistance and positions of greater hip flexion.

You can read more about specific exercises for proximal hamstring tendinopathy in our related article: Proximal Hamstring Tendinopathy Exercises.

Proximal Hamstring Tendinopathy exercises to avoid

Stretching can feel exactly like what the hamstring needs, as it often feels tight and stiff, as well as painful. However, a hamstring stretch will compress the hamstring tendon against the ischial tuberosity which can aggravate symptoms. It is therefore best to avoid hamstring stretches, in particular in the acute phase and if symptoms are aggravated. 

Other exercises that are to be avoided are those that also compress the tendon against the ischial tuberosity, such as a deep squat, straight leg deadlift, or seated hamstring curl. These should all be avoided in the early phases and only gradually reintroduced as tolerated in the later stages of rehabilitation.


How long does chronic high proximal hamstring tendinopathy take to heal?

Unfortunately, it is difficult to accurately give a specific time as every body and injury is individual. Generally speaking, hamstring tendinopathy can take 6-12 weeks to heal. Some people who address the pain very early may be able to reduce pain quickly and will only need a few weeks of activity modification. However, the longer symptoms persist before seeking treatment the longer recovery will take.

What causes proximal hamstring tendinopathy?

Causes include increases or changes in training and are particularly common in sports such as hockey, cycling, running (especially sprinting and hurdles), football and rowing. Typically there will be an increase in load on the hamstring that is beyond what it is capable of, this could be increasing the volume of training too quickly or changing to hill running for example.

Can I run with proximal hamstring tendinopathy?

Fast running and uphill running will load the hamstring more than slow and flat running, in addition, the flexion angle of the hip with fast and uphill running will be higher causing a greater compression of the hamstring tendon against the ischial tuberosity. Therefore, in many cases running can be continued but usually with adjustments, such as slower or avoiding hills, the volume may need to be reduced also.

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