Proximal Hamstring Tendinopathy

What is Proximal Hamstring Tendinopathy?

The word tendinopathy refers to dysfunction or degeneration of a tendon, often due to repetitive strain or excessive loading. Proximal Hamstring Tendinopathy (PHT) is a common overuse injury affecting the tendon of the hamstrings where they attach to the ischial tuberosity of the pelvis causing it to become irritated and inflamed, typically from activities that involve frequent hip flexion and knee extension, such as running, cycling, and rowing. While it can be frustrating and slow to heal, understanding the condition and following proper rehabilitation strategies can help individuals return to pain-free movement.

Unlike an acute hamstring strain, which results from a sudden overload, PHT is a chronic condition that develops gradually due to repeated stress and inadequate recovery.

Causes and Risk Factors

PHT is often linked to activities that place high tensile and compressive loads on the hamstring tendon, such as:

• Running (especially long-distance and sprinting) – Repeated hip flexion and knee extension strain the proximal tendon.

• Hill running or speed work – These activities place excessive load on the hamstrings.

• Prolonged sitting (especially on hard surfaces) – Sustained compression of the tendon can worsen symptoms.

• Hamstring stretching – Overstretching an already irritated tendon can delay healing.

• Sudden increase in training load – Rapidly increasing intensity, volume, or frequency of workouts can overload the tendon.

• Weak glutes and core instability – Poor biomechanics may contribute to excessive hamstring loading.

• Other contributing factors include poor flexibility, improper running form, previous hamstring injuries, and age-related tendon degeneration.

Signs and symptoms of Proximal Hamstring Tendinopathy

• Deep, aching pain in the lower buttock – Especially noticeable when sitting, running, or bending forward.

• Pain that worsens with activity – Running, lunging, or squatting can trigger discomfort.

• Tenderness when sitting – Pressing on the ischial tuberosity may elicit pain.

• Morning stiffness – The tendon may feel stiff and sore after rest.

• Pain when stretching the hamstring – Stretching often worsens symptoms rather than relieving them.

• If left untreated, PHT can become a persistent issue, significantly impacting an individual’s ability to engage in physical activity and daily tasks.

Diagnosis

A clinical evaluation by a chiropractor or physiotherapist is typically sufficient to diagnose PHT.

Key diagnostic methods include:

• Patient history – Understanding activity level, training load, and symptom progression.

• Physical examination – Palpation of the pelvis, hamstring strength tests, and functional movement assessments.

• Early diagnosis is essential to prevent further tendon damage and facilitate effective rehabilitation.

Treatment and Rehabilitation

1. Load Management

The first step in treatment is modifying activity levels to avoid excessive strain on the hamstring tendon. This may include:

• Reducing running volume and intensity.

• Avoiding aggravating activities like prolonged sitting and stretching.

• Using a cushioned seat or standing desk to minimise discomfort when sitting.

2. Strengthening Exercises

Gradual progressive loading is key to tendon recovery. A well-structured rehab program typically includes:

• Isometric exercises (early stage)

• Seated hamstring holds

• Bridge holds

• Eccentric and concentric strengthening (mid-stage)

• Romanian deadlifts

• Hamstring curls

• Functional and plyometric exercises (late stage)

• Single-leg deadlifts

• Hopping and sprint drills

These exercises help rebuild tendon capacity, improve strength, and restore function.

3. Avoid Excessive Stretching

While it may seem counterintuitive, aggressive hamstring stretching can worsen PHT by increasing tendon compression. Instead, focus on strengthening and mobility exercises that improve hip function without overstretching the tendon.

4. Address Biomechanics

Weak glutes along with poor pelvic stability / function can lead to increased hamstring strain. Incorporating chiropractic treatment, glute activation and core stability exercises (e.g., clamshells, side planks) can help correct movement patterns.

5. Pain Management

• Ice or heat therapy may provide temporary relief.

• Non-steroidal anti-inflammatory drugs (NSAIDs) can help with pain but should not be relied upon long-term.

• Shockwave therapy or dry needling may be used in stubborn cases.

6. Gradual Return to Activity

Once pain improves, a structured return-to-sport plan should be followed. Rushing back into high-intensity exercise can lead to re-injury. Instead, gradually increase running volume, avoiding excessive sprinting or hill running initially.

7. Prevention

To reduce the risk of developing PHT or prevent recurrence:

• Incorporate strength training – Maintain hamstring and glute strength with regular resistance exercises.

• Progress training gradually – Avoid sudden increases in running intensity or volume.

• Improve biomechanics – Work with a coach or physiotherapist to optimize running form.

• Use proper warm-up routines – Include dynamic stretching and activation drills before workouts.

• Manage sitting time – Take breaks and use cushions when necessary.

Final Thoughts

Proximal Hamstring Tendinopathy can be a challenging and frustrating condition, but with the right treatment approach, full recovery is possible. The key is early intervention, progressive loading, and patience in the rehabilitation process. By addressing underlying risk factors and following a structured rehab program, individuals can return to pain-free movement and prevent future flare-ups.

If you’re struggling with persistent hamstring pain, book in today at ADT Chiropractic for a personalised treatment and rehabilitation plan.