Proximal hamstring tendinopathy and how to treat it effectively

Proximal hamstring tendinopathy, another pain in the bum

Proximal hamstring tendinopathy (PHT)  is another true pain on the bum. It can  also be a tricky customer to diagnose and a stubborn one to treat. It is usually associated with a deep ache / pain felt around, where the glutes meet the upper thigh at the ischial tuberosity.

It is common injury found among distance runners and sprinters / hurdlers as well as this e involved in  sports that require cutting and sudden change-of-direction when running eg football codes. However it also a condition that can  affect the non sporting population and can  be associated with repetitive deep squatting , lunging and sitting.

What causes Proximal hamstring tendinopathy ?

In the sporting population the following factors may play a role in the development of PHT and may come down to too much load applied too soon creating too much compression at the tendon.

  • increasing training volume or intensity too quickly,
  • Activities that involve lengthening of the hamstring when the hip is flexed eg sprinting,
    lunging, hurdles, or hills. These activities may increase compression at the origin of the hamstring at the ischial tuberosity.
  • Introduction of static hamstring stretches in hip flexion  for example, yoga and Pilates postures.
  •  compressive load at the tendon may occur from simply sitting on the area for too long.

How do I know if I have proximal hamstring tendinopathy ?

The main symptom  is pain in the lower gluteal region which can sometimes refer down the hamstring into the back of the leg. Pain  is often felt mainly with  running at a faster pace in sporting populations  or while sitting for a prolonged time in non sporting people.

It often appears without any sudden injury and usually becomes worse over time with continued training and exercise.  There may also be a history of  repetitive or previous hamstring injuries in those participating in running related sports.

Clinically the following is often observed:

  • Tenderness and pain when palpating the tendon origin at the  ischial tuberosity.
  • This pain is increased on palpation with resisted knee flexion
  •  Active stretching of the hamstrings can recreate the pain at the site of the ischial tuberosity.

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The shoe off test: simplest test for proximal hamstring tendinopathy you can do right now.

Positive shoe off test can indicate PHT

try to take off your shoe  by  pulling the affected legs heel back against the other foot, pain in the hamstring denotes a positive ‘shoe off’  test.

These are other proximal hamstring provocation tests that also form part of rehab:

  • Short level bridge (low-load test)
  • Long lever bridge (moderate load test)
  •  ‘Raging bull’  or shoe off test  (moderate-high load test)
  • Arabesque (high load)
  • Single leg dead lift (high external load test) .


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Could my proximal hamstring tendinopathy be something else ?

This is why its important to get an assessment as there can sometimes be other diagnosis that masquerade as hamstring tendinopathy. Alternative diagnosis may include the following;

  • Stretch sensitive sciatic nerve pain
  • Referral from the lumbar spine or sacro iliac joint.
  • Piriformis type syndrome
  • Ischial bursitis

In rare cases that involve trauma there may be an avulsion fracture where the attachment comes away from the pelvis and in some very rare cases a stress fracture may be suspected.

Best treatment for Proximal hamstring tendinopathy

As with a lot of tendinopathy type treatments the following guidelines apply:

  • Modify activity to reduce the aggravating factors such as compressive loading.
  • Biomechanical modification to running style or exercises.
  • If required we may need to deload or rest the area to let it settle down.
  • Reload the tendon to build up its strength and capacity.

Exercise rehab for proximal hamstring tendinopathy.

Ideally when the hamstring has settled down as is not as irritable the most effective long term rehabilitation  is exercise focused.

This is an example of a staged exercise based on the program from  The journal sports physical therapy

Level 1:

The goal at this stage is to avoid compression but increase the load on the tendon. The simplest way to do this is with using static holds or isometrics.  The benefit of isometric exercise is that it may have an analgesic effect for tendon pain. Try 4-5  sets of 45-second holds at 70% maximal voluntary contraction for isometrics in this case.

In an irritable tendon we would normally start with isometrics only but often you can start with active strengthening as symptoms allow.

  • Single leg Bridge
  • Long lever bridge hold
  • Straight leg pull downs
  • Isometric back extensions

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Mid to Late stage rehab proximal hamstring exercises

Level 2:

  • Romanian deadlifts
  • Nordic hamstring curls
  • Hamstring curls in prone
  • Leg slides
  • Bridge progression e.g hip thrusts

Level 3:

  • Step ups
  • Lunges
  • Stiff leg deadlifts / deadlifts
  • Single leg RDL / Stiff leg deadlifts

For return to sports we need to also consider restoring the dynamic strength and spring like qualities of the tendon .

This would include more plyometric based exercises such as alternate lunge jumps, hopping and bounding. Read more here about this training topic.

Do you need to alter running style and proximal hamstring tendinopathy ?.

Everyone’s running style is different and it may be that your gait does not need changing.  However there are certain characteristics that are seen in runners with this condition that increase the load on the proximal hamstring:


  •  over-striding,
  • excessive forward trunk lean,
  • increased anterior pelvic tilt,
  • pelvic instability.
  • Poor hip extension





However if you do tend to overstride increasing your cadence may help along with the following tips :

  1. Run with shorter, faster steps
  2. Tighten your glutes
  3. Run tall, as if being pulled up by a helium balloon on your head!

You can get more of an overview of running technique and hamstring tendinopathy here at The running physio website.

If you want to know more about the importance of cadence and running you can read more here

When can i run again ? The recovery time for proximal hamstring tendinopathy.

This is the million dollar question everyone wants answered. The best way to look at it is regarding How much you flare up and how long it takes to settle.

A good guide is no more than an increase of symptoms above 3-4 / 10  on a pain scale and settling within 24 hours, hopefully less. Anymore than this may be too much.

To start running I’d start off very conservatively, dip your toe in the water so to speak and build slowly over a period of time. Its good to work with your physio about this as everyone is different and some may get back to their desired level quicker than others.

Rehab is still important  during your return to running even if you are symptom free. We still need to develop and increase the tendons load tolerance to prevent recurrence and build you back to the levels you want. Tendons are slow to build up strength compared to muscle and as such we need to persevere for longer.

Hopefully this helps you get on the road to recovery. If you are struggling with this condition please book in to see one of the team here

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Expert opinion: diagnosis and treatment of proximal hamstring tendinopathy.  2015 Jan-Mar; 5(1): 23–28.

Proximal Hamstring Tendinopathy – returning to running: Tom Goom , running physio blog