Proximal hamstring tendinopathy is an injury that involves the tendon and/or enthesis of the hamstring muscle where it attaches onto the ischial tuberosity of the pelvic bone at the bottom of the buttocks. Otherwise known as an insertional hamstring tendinopathy, it is common among long-distance runners and it is not typically associated with a single inciting event, but instead represents a chronic degenerative process produced by mechanical overload and repetitive stretch. Predisposing factors include overuse, poor lumbopelvic stability and weak hamstrings.

A proximal hamstring tendinopathy often presents as localised posterior thigh pain directly on or just below the large “sit bone” or ischial tuberosity. Patients may experience symptoms with prolonged sitting or driving in a car and stretching of the hamstrings make the situation gradually worse. Occasionally, symptoms of sciatic nerve irritation may also develop along with their posterior thigh pain, ranging from posterior thigh pain to radiating pains down the leg.

The diagnosis of proximal hamstring tendinopathy is based on the above symptoms, as well, during clinical examination, there is often palpable tenderness and pain over the ischial tuberosity against resisted knee flexion. Furthermore, active stretching of the hamstrings recreates the pain at the site of the ischial tuberosity as well. The Puranen-Orava test is performed by flexing the hip to 90°, while the knee is then passively extended and supported on a foot rest. Provocation of posterior thigh pain indicates a positive test. The bent-knee stretch test is performed with the patient supine and their knee and hip maximally flexed. The knee is then gradually extended until symptoms develop.

Rarely does there need to be further investigations, but an MRI or ultrasound would be first line. Imaging examinations may report findings associated with tendinopathy including increased tendon size, peri-tendinous T2 signal, and ischial tuberosity edema.

Initial management of chronic insertional hamstring tendinopathy consists of a variety of non-operative measures, including eccentric physiotherapy exercises, shock wave therapy, corticosteroid, or platelet-rich plasma injections.

• Avoid compressive load 

This means avoiding prolonged sitting as the proximal hamstring tendon is compressed against the bony prominence – ischial tuberosity. Also avoid stretching and foam rolling as irritable tendons don’t like these types of compressive load.

• Eccentric and/or heavy slow resistance

Eccentric exercises have been considered the mainstay of treatment for chronic insertional hamstring tendinopathy, despite a lack of supportive literature. This has largely been extrapolated from supportive studies in the treatment of Achilles or patellar tendinopathy. Eccentric exercise programs with musculotendinous junction strengthening and promotion of intratendinous collagen fiber cross-linkage to enable remodeling and flexibility improvement have demonstrated their potential in treating tendinopathy. More recently, heavy slow resistance (HSR) training, which consists of both concentric and eccentric exercises, has been investigated, showing some promise over eccentric exercises; however, further study is necessary to evaluate both forms of rehabilitation for this injury.

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• Ultrasound-guided corticosteroid injections

Ultrasound-guided corticosteroid injections have also been utilised in the management of proximal hamstring tendinopathy. Two studies have demonstrated significant improvements in pain scores immediately following injections, with no reported short- or long-term complications.. However, the durability of the results is unclear, as it appeared that only a minority (< 38%) of patients exhibited sustained relief 6 months after the injection. Nevertheless, it may represent a viable option in the initial non-operative treatment regimen.

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• PRP injections

PRP injections have been utilised for the treatment of chronic insertional hamstring tendinopathy; however, the quality of literature to support its use is relatively poor.