What is Proximal Hamstring Tendinopathy?
Proximal hamstring tendinopathy (PHT) is a painful condition affecting the hamstring tendons where they attach to the ischium of the pelvis. Many people with this condition often describe lower buttock pain that eases during exercise but usually returns.
It isn’t necessarily what you first think of when somebody mentions hamstring injuries.
When most people think of running-related hamstring injuries, they picture the classic image of a sprinter pulling up sharply mid-race, as if hit by a sniper shot. This kind of acute hamstring tear is indeed the most common type of injury to the hamstring muscle group.
However, a less well-known but surprisingly common injury, especially amongst endurance athletes (rather than sprinters) is proximal hamstring tendinopathy. This chronic injury is often difficult to rehabilitate, frequently resulting in long and frustrating interruptions in run training.
In comparison to acute hamstring muscle tears, there is little research into proximal hamstring tendinopathy (also known as high hamstring tendinopathy) in runners.
In this article, I’ll take a look at what the research tells us, in combination with my own anecdotal observations having worked with many runners suffering from this specific injury over recent years.
Anatomy of the Hamstring Muscles
There are actually three hamstring muscles at the back of each of your thighs: semitendinosus, semimembranosus and biceps femoris with its long and short heads. At the top of the muscle group, while the short head of biceps femoris attaches to the femur, all the other hamstring muscles share a common point of origin on the ischial tuberosity (sitting bones) of the pelvis. This point of attachment sits deep beneath the bottom part gluteus maximus (the bigger of your butt muscles).
At the bottom of the hamstrings, around the back of the knee, both semitendinosus and semimembranosus attach to the medial tibia, while biceps femoris attaches distally close to the fibular head, towards the outside of the knee.
Like all skeletal muscles, the individual hamstring muscles act to produce motion in all three planes of motion. However, the linear orientation of their fibres and lever arms at the hip and knee make them most effective in the sagittal (back and forth) plane.
When I was taught anatomy at school, the hamstring muscle actions were described at isolated joints, in an open-chain (non-weight bearing) situation. I was taught that the text-book function of the hamstrings is to contract concentrically to produce hip extension and knee flexion.
However, with the hamstrings being a two-joint muscle group (crossing hip and knee), when we run there are other considerations to take into account, especially during stance phase. During this phase, the foot is anchored to the ground by our body weight creating a closed chain environment. As the hamstrings contract with glute max to create hip extension, propelling us forwards they also create an extension moment at the knee… rather than knee flexion as we learnt at school!
More about this counterintuitive muscle function in a future post!
Symptoms of Proximal Hamstring Tendinopathy
The location of pain for runners suffering from proximal hamstring tendinopathy is specifically around the ischial tuberosity of the pelvis (the sit bones). Pain in this region is often described as ‘deep buttock pain‘, or ‘high hamstring pain‘.
As a quick side-note: proximal hamstring tendinopathy is classified as a tendinopathy rather than a tendonitis, due to it’s degenerative nature rather than being an inflammatory pathology.
Runners suffering with high hamstring tendinopathy will complain of buttock pain around the hamstring insertion area, especially when running at faster paces, and running uphill.
The pain of proximal hamstring tendinopathy is usually an intense ache in nature, rather than being sharp or stabbing as a muscular tear would be.
Occasionally, the sciatic nerve can also be affected, as it lies fairly close to the common hamstring tendon. This can cause referred pain into the posterior thigh. Once aggravated, direct pressure on the hamstring tendon can be painful, thus sitting on solid surfaces can also become uncomfortable, as can direct manual palpation and pressing onto the ischial tuberosity.
Can You Run With High Hamstring Tendinopathy?
It is possible to continue running with proximal hamstring tendinopathy. However, you may need to make alterations to your training plan. Avoid hill reps and speed work, as these types of running usually aggravate an irritable hamstring tendon.
The inevitable question when it comes to an annoying niggling injury like proximal hamstring tendinopathy is whether or not you can run through the injury. I’ve seen lots of runners successfully manage run with this injury, and continue training, perhaps for an upcoming marathon, simply by adapting their marathon training plan a little.
Knowing that speed work, and hill running are both usually aggravating factors for high hamstring tendinopathy, sufferers should consider removing these from their running training schedule, to prevent flare-ups. Stick to easy paced running, and working on building your aerobic base.
When it comes to running style, avoid the temptation to stride-out, as it’s this increased hip flexion that creates the loaded compression of the hamstring tendon that may exacerbate your tendinopathy.
Instead, focus on increasing your running cadence and making short-quick strides for the given pace.
Here’s an article full of running technique tips, which will explain how to increase your cadence, and why it’s important to do so: How to Increase Your Running Cadence
I’ve seen conscious simple changes to running technique make a huge difference to the symptoms of runners with proximal hamstring tendinopathy, to the degree that it allows them to continue training, albeit in a modified fashion.
Proximal Hamstring Tendinopathy Diagnosis
As with all running injuries, if you’re concerned that you may be suffering from proximal hamstring tendinopathy, it’s important to seek face-to-face medical advice, rather than simply consulting Dr Google, and coming to your own conclusions (oh, the irony!).
There are a number of different potential causes for the type of deep buttock pain that high hamstring tendinopathy sufferers know all too well. Piriformis syndrome, lower back injuries, and pelvic stress fractures, can all create a similar set of symptoms, and form a non-exhaustive list of differential diagnoses for proximal hamstring tendinopathy.
It’s not unusual for me to meet runners who have has their high hamstring tendinopathy misdiagnosed for piriformis syndrome, and vice versa… which has lead to ineffective rehab, and an extended period of rest from running. So frustrating!
This is why an MRI scan will often be used to support the diagnosis once and for all.
If your physio suspects you might be suffering from high hamstring tendinopathy, there are of course a number of manual tests they may use to confirm their hypothesis.
Testing For Proximal Hamstring Tendinopathy
In January of 2012 Cacchio et al., published a paper looking at the reliability and validity of three pain provocation tests used for the diagnosis of chronic proximal hamstring tendinopathy. Taking into account the need for further assessment of the three tests used in the study (listed and described below), the authors concluded that the chosen tests represent a valid, reliable means of testing for Proximal Hamstring Tendinopathy.
The three tests they used in the study are as follows:
In the Puranen-Orava test for proximal hamstring tendinopathy, the subject actively stretches the hamstring muscles in the standing position with the hip flexed at about 90°. The knee on the testing side is fully extended and the foot is up on a support
Bent Knee Stretch Test
The bent knee stretch test for proximal hamstring tendinopathy is performed with the patient lying supine (on their back). The hip and knee of the symptomatic leg are maximally flexed, and the examiner slowly straightens the knee.
Modified Bent Knee Stretch Test
In this test for proximal hamstring tendinopathy, the patient lies in the supine position with the legs fully extended; the examiner grasps the symptomatic leg behind the heel with one hand and at the knee with the other hand, maximally flexes the hip and knee, and then rapidly straightens the knee.
As mentioned earlier, MRI and ultrasound imaging provides a great diagnostic resource. MRI, in particular, can identify tendon thickening, tearing, inflammation, and swelling in the bone at the ischial tuberosity.
Proximal Hamstring Tendinopathy Treatment
Compared to other more common running injuries, comprehensive literature on proximal hamstring tendinopathy is fairly limited. However, in 2005 Frederickson et al., at Stanford University published an insightful paper reviewing treatment and rehabilitation guidelines for high hamstring tendinopathy in runners.
Following thorough assessment and diagnosis confirmed by MRI, Frederickson’s group evaluated injured runners for core strength, hamstring flexibility and pelvic stability. The following treatment options are recommended in their paper:
Soft Tissue Treatment, Manual Therapy & Stretching
Hands-on treatments providing soft tissue mobilisations to break up scar tissue and adhesions can be useful, as can transverse frictions to the affected tendon. Care should, however, be taken not to apply direct pressure to the ischial tuberosity itself. This sort of soft tissue work is complementary to a gradual introduction to regular hamstring stretching.
If upon assessment, pelvic misalignment (anterior innominate rotation in particular) is identified, manual manipulation to restore the alignment of the pelvic innominate bones is often useful in restoring proper hamstring function. The work of Cibulka et al., is mentioned, as they reported in their 1986 study that after one manual treatment to realign the pelvis, isokinetic hamstring peak torque was seen to increase by 21.5%.
The question, of course, must always be asked – where does the imbalance come from that caused the pelvic misalignment…?
Exercises for High Hamstring Tendinopathy
Yamamoto is cited for his 1993 work identifying hamstring-to-quads strength ratio (amongst other factors) as a variable affecting the risk of hamstring injury in runners. Although it’s not clear whether his findings also apply to proximal hamstring tendinopathy, Frederickson’s group identify hamstring strengthening as an important part of their rehabilitation guidelines.
They suggest that the progression of targeted hamstring exercises should go as follows:
- Isometric hold exercise:
90 Degree Hamstring Bridge Holds
- Single leg exercises:
Glute March Drill
Single Leg Hamstring Catch
- Loading through range:
Swiss Ball Hamstring Curls
Runner’s Arabesque (only when you’re ready to load into hip flexion)
For full details of sets and reps, feel free to download the rehab exercises worksheet linked below:
Core Strength & Pelvic Posture Correction – The Key Perhaps?
Hands-on treatments, stretching and progressive strengthening are all important components of any good rehabilitation plan for proximal hamstring tendinopathy. However, in my experience, I find the following core strengthening element to be the key to a successful outcome.
The paper by Frederickson et al., identifies the work of Sherry and Best (2004) in emphasising the vital importance of trunk stabilisation exercises in the successful rehabilitation of hamstring injuries. The emphasis is put on core strength exercises which help the athlete maintain a desired neutral pelvic position throughout dynamic movements.
It’s my experience that many of the athletes I’ve worked with who suffer from high hamstring tendinopathy, or recurrent hamstring strains, present displaying poor ability to control their pelvic position throughout the performance of functional movements for their sport.
Particularly, the tendency seems to be for them to fall into an anterior pelvic tilt / innominate rotation. Of course, this will put the hamstring in a position where they are chronically held on tension.
This article on Gluteal Inhibition further explains the contributing soft tissue imbalances that lead to this issue.
Re-educating proper pelvic position throughout movement, and working to correct imbalances which predispose an athlete to poor pelvic posture should, in my opinion, take equal, if not increased precedence over elements of the rehab programme such as eccentric hamstring strengthening protocols.
Below is an example of one of the various exercises I give athletes to help address imbalances which affect their pelvic posture in running gait.
Each athlete’s injury is, of course, different, but the guidelines above hopefully provide food for thought and some direction in the treatment and rehabilitation of such cases.
There are other treatment options available, in addition to the conservative options mentioned above. It’s not the remit of this article however to discuss options such as corticosteroid injections, shockwave therapy and surgical interventions.
Return to Running After Proximal Hamstring Tendinopathy
As with all running injuries, it is important to take a very gradual approach to your return to running after proximal hamstring tendinopathy. One of the biggest errors made by athletes is giving up on their rehab exercises as running is re-introduced to the programme. Hamstring problems have a nasty habit of becoming recurrent. It’s always my advice that once an athlete has suffered this sort of injury once, and successfully recovered, their rehab exercises become their maintenance exercises.
Here’s a useful programme to use to help ensure a safe re-introduction to running.
Interesting stuff, thanks for your input. I’ll be pleased to hear professional views and experiences from all those reading this, to try and add to the overall view of how we rehab this condition.
Your comments about compression of the tendon during flexion activity of the hip make lots of sense to me, when considered alongside the pelvic alignment / stability comments I made in the article – If asked to raise the thigh to horizontal, an athlete displaying an anterior tilting pelvis (or same sided anterior innominate rotation) will be in greater hip flexion in relative terms, when compared to if he/she was holding the pelvis in a neutral position (or proper alignment).
So it stands to reason that while correcting pelvic position and improving proximal control won’t directly affect the healing and remodelling process, it would help to reduce unnecessary compressive forces on the tendon, especially when late stage rehab and return to sport is reached.
Ultimately, the tendon has to be loaded, progressively of course, as a mainstay of the rehab – but I still put a big emphasis on making sure proximal control is maintained.
Perhaps the hip flexion component to the mechanism of injury explains why running at increased pace (relative to the athlete’s normal training load) is reported as being a common factor in the onset of this condition – longer stride length requiring greater hip flexion and increased hamstring loads through range?
Fair point re the “evidence based” treatment and rehab guidelines. I’ll go back and re-word accordingly!
Interesting article James. Have you listened to the BJSM Podcast below on classifying hamstring injuries and their subsequent management. It’s and interesting listen if you have a few minutes. I have found that starting with isometric strengthening exercises and not stretching helps initially and agree that assessing the pelvis and hip flexors is also key.
Excellent article! I’m suffering from a reactive proximal hamstring problem myself at present.
A couple of points to add – the work by Frederickson et al. (2005) is a fairly typical of his type of publications. Without meaning to be too critical of him, his pieces are perhaps more opinion based than research based. When you look at the evidence he presents there is little or nothing to show improved outcome with the approach he recommends. This is the case with some of his work into core stability as well. The problem then with this, as pointed out by Fizziowizzio, is that he makes some poor recommendations such as stretching which is likely to aggravate the condition by compressing the hamstring tendon against the ischial tuberosity.
Since his article our understanding of tendinopathy has progressed and, thanks largely to work by Cook and Purdam, we now know that “staging” the tendinopathy is important and that during the early ‘reactive’ stage our emphasis should be on reducing compressive and tensile load, especially activities like running up hill or over striding when running. In this stage isometric exercises done with the hip in neutral can be helpful too.
Alison Grimaldi has a great podcast on this topic in which she discusses isometrics and rehab progression, well worth a listen!
She also suggests trying to keep runners doing some running on the flat rather than complete rest, any thoughts on this? Would you favour rest from this activity in the reactive stage?
Great article James, and thanks to everyone for their comments. Tom, the Grimaldi podcast was great also. I am a frustrated runner who has been dealing with hamstring tendinopathy for years now, although must admit I kept running with it hoping it would go away for probably 2 years before I really took it seriously. After my third marathon of 2012 around Thanksgiving I knew I was in trouble and had to do something. I haven’t run since hobbling through a Turkey Trot last year and don’t know how much longer I can last without running (ok, that’s a little melodramatic but you runners out there know what I mean!). I have been trying everything in earnest since January – physical therapy with the ART, Graston, and eccentric exercises; a couple prolotherapy injections with 5% dextrose, acupuncture, trigger point dry needling, osteopathic manipulation, and massage. I never knew my hamstring could cost me so much money!
My pain is definitely better from it’s worst, down from an 8 to maybe a 3, but it seems stuck there. My doctors and therapists have all insinuated that I shouldn’t run if I can still feel the pain even with walking. Frankly, I always have a low level ache that now I’m so acutely aware of I even feel it while lying in bed. (and while I’m sitting here typing this message!) I had one doctor who told me I was cured after I couldn’t really feel the pain immediately after he dry needled some spots. Of course, I could feel the pain by the time I walked to my car in the parking lot.
It was interesting that Grimaldi seems to be ok with continuing to run if it’s not making the pain worse and she didn’t say wait until “pain-free”. Also, she said not to do dead lifts or “good mornings” which has been part of my PT eccentric exercises for a while now. I was signed up to do Big Sur Marathon this April but obviously had to bag that idea, especially with all those hills. Now I’m signed up for Chicago in October, which is super flat but I’m still nervous about that fact that it’s not 100% better. Maybe it will never be? I can live with a 1-3 pain level with running if I’m not going to make it worse again.
Anyway, thanks for reading and letting me vent. Any and all opinions and personal anecdotes are very much appreciated!
I am currently dealing with a continuous pain in the glute area. I’ve been through several misdiagnoses, including ‘piriformis syndrome’ which is most common with injuries like this. During this frustrating time of misdiagnoses (almost 9 months) several physical therapists had me stretching the piriformis which I always felt was making the pain worse. The constant pain was a localized uncomfortable ache with some throbbing while sitting or when taking off a shoe. Every physical therapist seems to thing stretching is the answer, I don’t and I’m not a doctor. Nothing was making it better, and I’m a 26 year old male and very active/athletic.
I’ve since seen an osteopathy sports doctor who identified a minor strain in the hamstring. She administered a ultrasound guided injection and some dry pricks to stimulate the healing. After a couple weeks, it did not feel better from just the injection. Before the knowledge of a hamstring strain I had not done one exercise where the main muscle was the hamstring. So I decided to try some low-weight leg curls (seated and laying down) and even after one day of these exercises the constant nagging pain subsided. I saw the osteopathy sports doctor one more time and she advised to keep doing them for another couple weeks and then try running 0.5 miles every other day. She also scheduled an MRI for the same week. The MRI results came back completely NORMAL.
Here it’s been another month and while the constant pain is not all there, I believe it’s being re-aggravated and will be triggered further by running a longer distance. I tried stretching and it makes it worse. I feel like I’ve made progress and now it’s back to the way it was. I’ve read some of the comments and I believe long-stride and fast pace has a lot to do with this. I’m stuck and I’m so frustrated I just want the pain to go away so I can run again.
My search on “proximal hamstring strain” has led me to this website which I’ve been trolling for some time now this morning! At first, I felt I had found some vital information that I could use in order to rehabilitate myself, but now I’m feeling overwhelmed with all of the information. I guess this is exactly why physical therapy is so popular. It can be difficult to figure out a plan for yourself, however, I’m going to try due to insurance issues.
I’m a runner! I was first going to say that I am merely a jogger, as my times would not indicate a seasoned runner, but I decided I’m not going to lesson the fact that I’m a runner. (Even if my 5k time is roughly 32 minutes 🙂 ). I first started “running” for exercise, but now I’m a little addicted. I had continued running outside until January 10th of this year when I needed to finally bring it inside to a dreadmill. The weather here in Chicagoland just did not help when it came to running outside!!
My running in, or outside, was not what caused my issues. On February 22nd I was out with friends and um, did the splits (hehe). Not only did I do the splits, but my body wanted to stop about a foot from the floor. I bounced my body in order to lower myself down further. OOOPS!! The moment I got up I could feel it. A burning in the upper part of the back of my leg. (It is important to not that I DID do the splits!!!!) But now I’m suffering those consequences 🙁
I have not run for 3 weeks in an attempt to heal this injury. I did go to the Ortho doc yesterday and it is apparent that I have a Hamstring strain with sciatic involvement likely. He passed up on doing an MRI because he said the result would still be the same. Physical therapy. I asked if I could start running again, and he told me I’m an adult and can make that decision, but by doing so I could end up with a much bigger problem. He explained that the position of this hamstring strain typically takes a lot longer to heal. He also sees that it is recurring and takes a lot longer in runners, because they do not take the advice of not running!
My symptoms are as follows:
Pain in the upper part of the leg. Pain when sitting and placing pressure on right buttock. I often have to position my body so that the weight is put on the opposite side of my body. Squatting hurts. I attempted a burpee, and that is also a no no UGH! I feel as though I could start some running on the treadmill at a slow pace with smaller steps, but I really don’t want to aggravate my symptoms and create long term problems. I’ve thought about popping a pain patch onto the area or lathering myself up with BenGay and going out for a run! But sadly, I know, that this will just temporarily mask the pain while perhaps doing further damage.
If anyone would like to play doctor and offer up a few exercises I could do to try to rehabilitate myself, I would be forever grateful. Please do not tell me that at 42, I shouldn’t be playing cheerleader in the local bar 🙂
I have been following this thread for over 2 years now (about how long I have been dealing with this injury). I have had numerous physical therapists, multiple hip MRIs, multiple injections, and years of rest from running. Obviously, none of it helped. I wanted to write because I actually found an exercise regimen that worked in less than 2 weeks. Yes, I took it upon myself to attack this problem under my own hypothesis and it worked. I am now running again which I thought was an impossibility.
First, buy a stability disk and a medium resistance band. I did the following exercises consecutively for three sets daily:
Lateral leg raises (standing) – 10-15 reps
Lateral leg raises (standing with resistance band) – 10-15 reps
Lateral leg raises (standing on stability disc) – 10-15 reps
One-Leg Bridge Lifts (on stability disc) – 10-15 reps
Results after two weeks allowed me to run with virtually no pain. I am taking it slow getting back into running but these exercises have triggered healing almost immediately. I’m kicking myself that I didn’t think to do this earlier or why no physical therapist was giving me the correct exercises.
Your rehab routine is interesting. What it sounds like is you are concentrating on strengthening the gluteal muscles. By strengthening your flute muscles did this heal your tendinopathy?
Thanks for keeping us updated and sharing your experience.
Wow that is really interesting! What a lot of people fail to overlook are antagonistic and synergistic muscles of the hamstring when they have tendinopathy. They feel their hamstring is tight/grumbly and stretch and strengthen that but in fact the issue is related to the muscles around it.
In your case it sounds like as you strengthened the glutes and hip flexors it pulled your pelvis into better alignment and/or allowed your body to recruit the right muscles more efficiently.
Maybe if you added some hip mobility drills you would see some more progress? It could seriously reverse the effects of the sitting.
Check out the Paleo chair, it’s supposed to be a very good practice for restoring hip strength and mobility.
Thanks again for your input! I’m 25 and been dealing with this for years. It sucks and I really want to put this behind me.
Sorry i didnt see your response.
I found this routine helpful for hip tightness and mobility issues.
I’m going to get a band and a stability ball and try out those exercises. My glute minimus and medius are so weak. I think my body is compensating by recruiting the hamstring and lower back.
I’ll give it a shot thanks are you still back to running?
I do exercises on both sides but sometimes only to the affected side. I run about 2-3 5k’s per week. Right now, I run indoors on a treadmill because its freezing in upstate NY. I try to stay away from steep hills although i feel as though I’ve built up enough strength to go up hills.
Please see Tom Goom’s exercises above – they work even better than the ones I posted. The bridge hold’s I find to be the most beneficial. Thanks Tom!!!
Free 30 Day Challenge
Free Marathon Training Plans
Free Half Marathon Training Plans
Bulletproof Runners Programme