<< Back to BLOG Homepage

Known collectively as the “hamstrings,” the Biceps Femoris, Semitendinosus, and Semimembranosus are important muscles that play a crucial role in walking, running, sitting, and standing, primarily due to their involvement in hip and knee movements. 

 

Hamstring injuries often occur in athletes, such as runners, and range in severity from sprains to degenerative injuries (Lempainen et al., 2015). Among these injuries is proximal hamstring tendinopathy (PHT), which affects the tendon where your hamstrings attach to the ischial tuberosity (the bony prominence you sit on). Therefore, this is an insertional tendinopathy

PHT presents as deep, localised pain in the lower buttock that can radiate into the posterior thigh. This pain typically worsens with activities that involve hip flexion (bending at the hip joint). 

​

​

​

​

​

​

​

​

​

​

​

 

 

 

 

 

 

 

Why does PHT occur?

 

PHT typically develops gradually, making it difficult to associate symptoms with a single traumatic event. Unlike acute hamstring strains, which result from sudden overload or tearing, PHT arises from repetitive tensile and compressive loading of the proximal hamstring tendons over time (Pietrzak et al., 2018).

• Tensile loading: stretching of hamstrings.

• Compressive: tendon contact with bone.

 

A key contributing factor is a sudden increase in activities that involve hip flexion, such as sprinting, lunging, or prolonged sitting. These movements stretch the hamstring tendons while simultaneously compressing them against the ischial tuberosity, creating an environment that can trigger tendon overload (Pizzari, Green & van Dyk, 2020).

 

This dual loading, tensile and compressive, can exceed the tendon’s capacity to adapt, especially when training loads are increased too quickly or without adequate recovery. Over time, this leads to structural changes within the tendon which are consistent with the continuum model of tendinopathy (Cook & Purdam, 2009; Dixon et al., 2023).

​

Put simply, in the case of PHT, doing too much too soon can overwhelm the tendon’s ability to recover, leading to pain and dysfunction.

​

​

​

​

​

​

​

​

​

​

​

​

​

​

​

​

 

​Risk Factors:

 

Research shows that a mix of intrinsic and extrinsic factors may increase the likelihood that someone will develop PHT (Goom et al., 2016). These include:

• Older Adults 

• Males 

• Genetic predisposition 

• Menopause 

• Hamstring weakness 

• Increased body mass index (BMI) 

• Diabetes mellitus 

 

Management:

 

Evidence-based approaches to tendinopathies balance progressive tendon loading and pain management (Goom et al, 2016). Throughout the process, it is important for pain to be individually assessed, and this can be done using a 0-10 scale. Typically, stable pain is considered to range between 0-3 if pain post-exercise does not exceed 24 hours.

 

In the early stages, the primary goal is to reduce irritation and symptoms. Activities that involve hip flexion should be temporarily avoided until the tendon can tolerate them without flare-ups. To maintain cardiovascular fitness, cycling in an upright position or swimming may be more suitable as they reduce compression at the tendon’s insertion (Goom et al., 2016). 

 

Rehabilitation:

 

Progressive loading is crucial to tendinopathy rehabilitation to build strength and resilience.

​

• Isometric exercises (Goom et al, 2016): Once pain is stable, rehabilitation moves to progressive tendon loading. The first stage involves isometric exercises, which are beneficial for improving tendon load tolerance and reducing pain. To minimise provocation, isometric exercises should initially be performed in positions of minimal hip flexion. These exercises involved holding a position so that the muscle length does not change. 

• Isotonic exercises (Goom et al, 2016): As symptoms reduce to a minimum, isotonic exercises can be introduced in positions of reduced hip flexion. This approach will help minimise irritation while load tolerance builds to increase muscle strength. As this becomes more tolerable, greater degrees of hip flexion can be implemented to strengthen the hamstrings in more functional positions required for return to sport. Exercises that load the hamstrings at length are best for tendon adaptation (Dizon et al., 2023).

• Kinetic chain exercises (Rich et al, 2025):The kinetic chain, or the muscles that are located along the back of the body have an influence on each other. Therefore, strength training that targets the structures nearby, such as the glutes, calves and inner thigh muscles, aims to improve overall power. Additionally, lumbopelvic control exercises can be included to reduce strain on the hamstrings tendon and may reduce re-injury risk (Dizon et al, 2023).

• Energy storage movements (Goom et al, 2016): If returning to high-impact or explosive exercise/sport where the hamstrings are required to store and release energy quickly, dynamic exercises may be appropriate. These can include bounding, skipping and cutting and should be started if there is adequate strength in single-leg exercises. 

 

Adjunct Therapies:

​

• Extracorporeal Shockwave Therapy (ESWT): ESWT has been shown to reduce pain and improve muscle function, especially when used alongside an exercise program (Dixon et al, 2023). It may be beneficial for individuals with persistent symptoms for pain modulation due to its inhibitory effect on pain (Goom et al, 2016; Pietrzak et al, 2018). One study found that ESWT was superior in the short and long-term for pain scores (Korakakis et al, 2018). 

• Massage: In early stages, massage can be used as an added therapy to address hamstring flexibility, tone and kinetic chain restrictions (Goom et al, 2016; Nasser, 2021).

• Corticosteroid injection: At a cellular level, corticosteroids help to limit chronic inflammation, which consequently reduces tendon scarring and adhesion formation (Pietrzak et al, 2018).

​

​

​

​

​

​

​

​

​

​

​

​

​

​

​

 

 

​​

​

 

 

Bibliography

 

Cook, J.L. and Purdam, C.R. (2009). Is tendon pathology a continuum? A pathology model to explain the clinical presentation of load-induced tendinopathy. British Journal of Sports Medicine, 43(6), pp.409–416. doi:https://doi.org/10.1136/bjsm.2008.051193.

 

Dizon, P., Jeanfavre, M., Leff, G. and Norton, R. (2023). Comparison of Conservative Interventions for Proximal Hamstring Tendinopathy: A Systematic Review and Recommendations for Rehabilitation. Sports, 11(3), p.53. doi:https://doi.org/10.3390/sports11030053.

 

Goom, T.S.H., Malliaras, P., Reiman, M.P. and Purdam, C.R. (2016). Proximal Hamstring Tendinopathy: Clinical Aspects of Assessment and Management. Journal of Orthopaedic & Sports Physical Therapy, [online] 46(6), pp.483–493. doi:https://doi.org/10.2519/jospt.2016.5986.

 

Korakakis, V., Whiteley, R., Tzavara, A. and Malliaropoulos, N. (2018). The effectiveness of extracorporeal shockwave therapy in common lower limb conditions: a systematic review including quantification of patient-rated pain reduction. British Journal of Sports Medicine, [online] 52(6), pp.387–407. doi:https://doi.org/10.1136/bjsports-2016-097347.

 

Lempainen, L., Johansson, K., Banke, I.J., Makela, K., Sarimo, J. and Niemi, P. (2015). Expert opinion: diagnosis and treatment of proximal hamstring tendinopathy. Muscles, Ligaments and Tendons Journal, [online] 5(1), p.23. Available at: https://pmc.ncbi.nlm.nih.gov/articles/PMC4396672/#sec5 [Accessed 28 Oct. 2025].

 

Nasser, A.M., Pizzari, T., Grimaldi, A., Vicenzino, B., Rio, E. and Semciw, A.I. (2021). Proximal hamstring tendinopathy; expert physiotherapists’ perspectives on diagnosis, management and prevention. Physical Therapy in Sport, 48, pp.67–75. doi:https://doi.org/10.1016/j.ptsp.2020.12.008.

 

Pietrzak, J.R., Kayani, B., Tahmassebi, J. and Haddad, F.S. (2018). Proximal hamstring tendinopathy: pathophysiology, diagnosis and treatment. British Journal of Hospital Medicine, 79(7), pp.389–394. doi:https://doi.org/10.12968/hmed.2018.79.7.389.

 

Pizzari, T., Green, B. and van Dyk, N. (2020). Extrinsic and Intrinsic Risk Factors Associated with Hamstring Injury. Prevention and Rehabilitation of Hamstring Injuries, pp.83–115. doi:https://doi.org/10.1007/978-3-030-31638-9_4.

​

​

​

​

​

​

​

​

​

​

​

​

​

​

​​​​​​​​​​​​​​​​If you would like to know more about Proximal Hamstring Tendinopathy and it's treatment, please contact us on 01949 485084