Proximal Hamstring Tendinopathy

Proximal Hamstring Tendinopathy

Article by Zoe Russell

Proximal Hamstring Tendinopathy

Hamstring Tendonitis

What is Proximal Hamstring Tendinopathy?

Proximal hamstring tendinopathy is also known as high hamstring tendinopathy. It is the term for an injury to the hamstring origin tendon at its attachment site into the pelvis’s ischial tuberosity.

Who Suffers from Proximal Hamstring Tendinopathy?

Proximal hamstring tendinopathy is most common in the middle to long-distance runners and those who participate in repetitive jumping, kicking and running sports such as soccer (football) and AFL.

Proximal Hamstring Tendinopathy Symptoms

Proximal hamstring tendinopathy often presents with the gradual onset of pain and is less likely with acute trauma.

Sufferers’ often report:

  • Deep buttock pain – constant and dull that is worsened with activity.
  • Pain in the posterior thigh
  • Pain can radiate down the thigh towards the knee along with the hamstring muscles.

Pain is always related to loading the hamstring muscles and increasing repetitive activities such as running and football codes. In some cases, pain can be elicited with the compressive force on the hamstring insertion from sitting.

What Causes Proximal Hamstring Tendinopathy?

proximal hamstring tendinopathy

The hamstring tendon’s role is to transfer the force of the hamstring muscle group to the pelvis. The hamstrings are prone to tendinopathy. They contribute to the straightening knee’s decelerating during activities such as sprinting and hill-climbing (Petersen et al., 2005).

When you apply an exercise load to the hamstring tendon’s proximal portion, the tendon is responsible for transferring this load to the pelvis. The normal tendon strengthening process occurs when the tendon has to undertake this action repetitively. The tendon adapts to withstand the pressure. These healthy tendon changes keep your body participating in your chosen activity at the performance level required for as long as possible. Usually, the tendon is capable of intrinsic repair, meaning that the consequences of loading are minimal and recover in preparation for the next bout of exercise (usually 24 hours).

However, if you continually apply an excessive load to the tendon, these changes occurring in the tendon can exceed the repair rate. This repetitive tendon overload results in tendon pain and dysfunction. In some cases, the inability to repair is a multitude of factors that can result in the repair not occurring and reduce the tendon’s ability to adapt. In some cases, this can even result in failed healing. This leads to tendinopathy formation (Kannus 1997, Sharma and Maffulli 2005, Warden 2007).

Proximal Hamstring Tendinopathy Risk Factors

Several factors can contribute to the development of proximal hamstring tendinopathy. Your physiotherapist is the best person to discuss these factors. Tendinopathy physiotherapists are skilled to identify all the contributing factors concerning your tendinopathy.

In some cases, proximal hamstring tendinopathy may occur following an acute hamstring tear. However, in most cases, tendinopathy is an overuse injury. Several intrinsic (within the athlete) and extrinsic (external to the athlete) factors may increase the likelihood of developing an injury.

Intrinsic Risk Factors:

  • Previous injury – loss of muscle strength and flexibility may predispose an athlete to injury.
  • Gluteal muscle dysfunction – reduced gluteal muscle strength can increase the hamstring strength requirements during activity.
  • Anterior pelvic tilt – an athlete in anterior tilt may increase compressive forces across the ischial tuberosity.
  • Female gender.
  • Overweight.
  • Core weakness – Core muscle strength is required to ensure that you maintain pelvic alignment during activity. Loss of pelvic control may result in increased loads through the hamstring tendon at the pelvis.
  • Stiffness of the hip – loss of active hip motion may increase dynamic movement’s hamstrings and pelvis requirement.

Extrinsic factors:

  • Training Load Changes – A sudden change in load, most commonly an increase in capacity, can be associated with PHT; alternately, a period of unloading (e.g. a holiday, off-season) and a sudden boost to your regular load may be enough.
  • Training errors – inadequate rest between training sessions, poor technique
  • Inadequate equipment – old or worn footwear
  • Insufficient warming up and recovery methods.
  • Fatigue – Injury risk can significantly increase when the body is tired.

Your physiotherapist will address any of these factors that may be influential. If you have any specific concerns that you would like them to investigate, please ask your physiotherapist.

Tendinopathy Phases

Tendinopathy is a continuum of pathological processes. Your treatment plan requires correct identification of the current phase of injury and applying appropriate exercise to rehabilitate your injury. Inappropriate loading may delay your recovery and your return to sport.

Identification of the phase helps identify an entry point for your rehabilitation and how much you can perform in your recovery and balance your activity levels in your rehabilitation plan.

It is imperative to have your tendinopathy professionally assessed to identify your injury phase. Identifying your tendinopathy phase is vital to direct your most effective treatment since specific modalities or exercises should only be applied or undertaken in distinct tendon healing phases.

How is Proximal Hamstring Tendinopathy Diagnosed?

Proximal hamstring tendinopathy is one of many causes of lower buttock pain. The correct diagnosis is vital to your treatment plan and recovery!

Your diagnosis involves a combination of your history of injury and pain provocation tests. Your physiotherapist or a sports doctor can confirm the diagnosis clinically. Diagnostic imaging is optional in your diagnosis. Imaging such as MRI is often used to exclude other conditions that mimic pain similar to proximal hamstring tendinopathy.

In some cases, an MRI ensures that your injury is proximal hamstring tendinopathy and not a complete rupture of the tendon. MRI can also be used to visualise any bone marrow oedema at the ischial tuberosity in conjunction with your injury.

Proximal Hamstring Tendinopathy Treatment

Your physiotherapist is highly skilled in the management of proximal hamstring tendinopathy. Among other tests, your physiotherapist will use your pain provocation tests, strength measures, and functional activities as a valuable tool to monitor your pain, function and when to progress exercises or return to sport. They will also oversee your subsequent safe return to sport.

They’ll also be happy to discuss your injury rehabilitation with your coach.

How Do You Treat Proximal Hamstring Tendinopathy?

Proximal hamstring tendinopathy treatment has progressed significantly in recent years. Based on this, it is now more important than ever to be assessed and treated by a tendinopathy physiotherapist. They will be up-to-date in the latest proximal hamstring tendinopathy research findings and treatment strategies.


There is increasing importance in exercise in the management of tendinopathy. Isometric exercise, or the joint angle and muscle length that does not change during use, has proven pain relief effects for athletes suffering from tendinopathy.

Treatment Progression

Tendinopathy treatment is progressed based on your tendon’s ability to withstand your exercises load. For most athletes, the traffic light system defines how much training is too much clearly.

Red will indicate that you need to reduce your exercise load. Amber suggests that you can exercise at your current limitations. Green indicates that you can safely increase your exercise loads.

Your physiotherapist will explain how to interpret your symptoms and plan your exercise loads based upon their assessment and your symptoms.

Managing Your Activity Load is the Priority!

Appropriate exercise load management is vital to the successful treatment of proximal hamstring tendinopathy. Mild load increases will stimulate new tendon growth, whereas overload leads to tendinopathy deterioration. Getting the balance right is critical.

Reduce the load to a level that allows the tendon to recover. In severe cases, this may mean total rest from your sport or modifying training depending on tendinopathy severity. Discuss your activity load with your physiotherapist, who will plan and adjust your program accordingly, based on your pain-provoking tests, traffic light response to activity and other symptoms.

When managing load, you should be guided by how the tendon responds immediately and 24 hours later. Tendons are known to have a latent response to loading. This latency means they can take 24 hours or more to react. It is essential to modify your activity to remain pain-free during and after 24 to 48 hours.

Proximal Hamstring Tendinopathy Prognosis

If you identify your hamstring tendon injury in the early stages, load management and reduction will allow the tendon time to adapt and quickly recover.  The reactive stage can be relatively short. Pain may settle in 5 to 10 days, but the tendon will still be sensitive to high loads, and training needs progression gradually to prevent relapse. It mustn’t progress into late-stage two or stage 3 tendinopathy. These tendinopathies require additional time and rehabilitation.

Brukner and Khan (2002) suggested that a likely return to sport is in the order of 12 weeks. However, everyone is very different!

Some practitioners suggest that the tendinopathy phase can sum up the prognosis with guided treatment:

  • Phase I: days
  • Phase II: weeks
  • Phase III: months
  • Phase IV: years

Exercises to Avoid with Proximal Hamstring Tendinopathy

Avoid exercises that provoke your pain, such as running up hills or stairs, bending forward with a straight knee (e.g., hockey) until advised otherwise by your physiotherapist.

Massage, Foam Rollers & Stretches

Massage or foam roller of your gluteals, quadriceps, ITB, and hamstrings may assist in cases of hamstring tendinopathy. You can perform these in positions that do not hyperflex your hip with a straight knee. Ask your physiotherapist for specific advice.

Eccentric Strengthening

Eccentric exercises were, for many years, the “go-to” exercises for tendinopathy rehabilitation. While important, premature or overloaded eccentric exercises can delay your recovery. Your physiotherapist will guide you when appropriate. Your strengthening should not aggravate your hamstring tendinopathy. They may start you with isometrics that avoid tendon compression and progress from there towards a basic and then advance eccentric exercise program.

Adjacent Joints & Lower Limb Biomechanics

Researchers have identified several lower limb biomechanical issues that may predispose you to hamstring tendinopathy. Your physiotherapist will thoroughly assess you. They may measure your ankle dorsiflexion, gluteal control, hip and knee bend ratio, plus analysis of your running and landing technique. They’ll advise you if you require some treatment to address any deficiencies.

Other Treatments

Novel therapies such as the injection of sclerosing agents, platelet-derived growth factor (PDGF), and autologous blood into diseased tendons have shown promising results, but more clinical trials are needed. Your physiotherapist is happy to discuss these options with you when they consider them an appropriate treatment option.

Remember, all tendinopathies are different. Please seek the advice of your trusted hamstring or tendinopathy physiotherapist to determine the best rehabilitation appropriate to your hamstring tendinopathy.

Article by John Miller

Common Youth Leg Injuries

Why are Children's Injuries Different to Adults?

youth sports injuries

Adolescent Leg Injuries

Adolescent injuries differ from adult injuries, mainly because the bones are still growing. The growth plates (physis) are cartilaginous (strong connective tissue) areas from which the bones elongate or enlarge. Repetitive stress or sudden large forces can cause injury to these areas.

In the adolescent leg, common injuries include:

Osgood-Schlatter's Disease

Pain at the bump just below the knee cap (tibia tubercle). Overuse injuries commonly occur here. The tibia tubercle is the anchor point of your mighty quadriceps (thigh) muscles. Because of excessive participation in running and jumping sports, the tendon pulls bone off and forms a painful lump that will remain forever. This type of injury responds to reduced activity and physiotherapy.

More info: Osgood Schlatter's Disease

Sinding-Larsen-Johansson Disease

Pain at the lower pole of the knee cap (patella). Overstraining causes Sinding-Larsen-Johansson disease. Because of excessive participation in running and jumping sports, the tendon pulls bone off the knee cap. This type of injury responds to reduced activity and physiotherapy.

More info: Sinding Larsen Johansson Syndrome

Anterior Knee Pain

Anterior knee pain or patellofemoral syndrome frequently gets passed off as growing pains. Cause of this pain includes overuse, muscle imbalance, poor flexibility, poor alignment, or more commonly, a combination of these. Anterior knee pain is one of the most challenging adolescent knee injuries to sort out and treat. Accurate diagnosis and treatment with the assistance of a physiotherapist with a particular interest in this problem usually resolves the condition quickly.

More info: Patellofemoral Pain Syndrome

Knee Ligaments

The cartilage between the leg bones has a better blood supply and is more elastic in adolescents than adults. As adolescents near the end of bone growth, their injuries become more adult-like. Hence more meniscal and ACL (anterior cruciate ligament) injuries are likely. MCL (medial collateral ligament) injuries result from a lateral blow to the knee. Pain felt on the inner side (medially) of the knee. MCL injuries respond well to protective bracing and conservative treatment.

More info: Knee Ligament Injuries

ACL (Anterior Cruciate Ligament) Injuries

This traumatic knee injury is significant. Non-contact injuries of the ACL are becoming more common than contact injuries of the ACL. Adolescent females are at high risk. Combination injuries with MCL or menisci are common. Surgical reconstruction is needed if the adolescent wishes to continue participating in "stop-and-start" sports.

More info: ACL Injury

Meniscal Injuries

Your meniscus is crescent-shaped cartilage between the thigh (femur) and lower leg (tibia). Meniscal injuries usually result from twisting. Swelling, catching, and locking of the knee are common. If physiotherapy treatment does not resolve these damages within six weeks, they may require arthroscopic surgery.

More info: Meniscus Tear, Discoid Meniscus

Sever's Disease

Heel pain is commonplace in young adolescents due to the stresses of their Achilles tendon pulling upon its bony insertion point on the heel (calcaneum). It is a common overuse injury due to excessive training and competition, particularly when loads are increased dramatically in a short period. Diminished flexibility and muscle-tendon strength mismatching may predispose you. Physiotherapy, reduced activity, taping and orthotics are the best ways to manage this debilitating condition for the active young athlete.

More info: Sever's Disease

Ankle Sprain

An ankle sprain is probably the most common injury seen in sports. Ankles sprains involve stretching of the ligaments and usually occur when the foot twists inward. Treatment includes active rest, ice, compression and physiotherapy rehabilitation. With the correct treatment, a low ankle sprain usually improves in two to six weeks. Your ankle physiotherapist should check even simple ankle sprains to eliminate high-ankle sprains. A residually stiff ankle post-sprain can predispose you to several other lower limb issues.

More info: Sprained Ankle

Patellar Instability

Patellar (kneecap) instability can range from partial dislocation (subluxation) to dislocation with a fracture. Partial dislocation treatment is conservative. Dislocation with or without fracture is a much more severe injury and usually will require surgery.

More info: Patella Dislocation

Osteochondritis Dissecans

The separation of a bone from its bed in the knee joint is Osteochondritis Dissecans (OCD). This injury is usually due to one major macro event with repetitive macro trauma that prevents complete healing. This injury is potentially severe. Treatment varies from rest to surgery. An Orthopaedic Surgeon's opinion is vital.

More info: Juvenile Osteochondritis Dissecans (JOCD)

Growth Plate Fractures

A fracture through the growth plate can be a severe injury that can stop the bone from growing correctly. These fractures should be treated by an Orthopaedic Surgeon, as some will require surgery.

Avulsion Fractures

youth pelvis hip avulsion

Image source:

An avulsion fracture occurs when a small segment of bone attached to a tendon or ligament gets pulled away from the main bone. The hip, elbow, and ankle are the most common locations for lower limb avulsion fractures in young sportspeople.

Treatment of an avulsion fracture typically includes active rest, ice and protecting the affected area. This active rest period is followed by controlled exercises that help restore range of motion, improve muscle strength and promote bone healing. Your physiotherapist should supervise your post-avulsion exercises. Most avulsion fractures heal very well.  You may need to spend a few weeks on crutches if you have an avulsion fracture around your hip. An avulsion fracture to your foot or ankle may require a cast or walking boot.

An excessive gap between the avulsed bone fragment and main bone may not rejoin naturally in rare cases. Surgery may be necessary to reunite them. In children, avulsion fractures that involve the growth plates also might require surgery. All avulsion fractures should be reviewed and managed by your trusted physiotherapist or an Orthopaedic Surgeon.

For more information regarding your youth sports injury, please consult your physiotherapist or doctor.

Youth Leg Injuries

Pelvis & Hip


Heel & Ankle

Common Youth & Teenager Sports Injuries

Common Youth Neck & Back Pain

Common Youth Arm Injuries