Proximal Hamstring Tendinopathy: 

If you’ve been dealing with deep buttock pain that gets worse when you sit or exercise, you might be experiencing something called proximal hamstring tendinopathy. This is a common issue for active people, especially runners and cyclists, but it can affect anyone. Others names for this type of injury can include hamstring origin tendinopathy, high hamstring tendinopathy or hamstring tendon injury. In this blog, we’ll break down what it is, why it happens, and how you can treat and prevent it.

What is hamstring tendinopathy?

Hamstring tendinopathy is when the tendons that connect your hamstring muscles to your pelvis become irritated or damaged over time. The hamstrings are a group of three muscles at the back of your thigh. These muscles attach to your ischial tuberosity—commonly known as the sit bone.

Is hamstring tendinopathy the same as a tendon tear?

Not exactly. A tendon tear usually happens suddenly and feels like a sharp pain. Tendinopathy, on the other hand, builds up slowly over time due to overuse or repetitive stress.

Is hamstring tendinopathy the same as a hamstring strain?

No. A strain affects the muscle or muscle-tendon junction, while tendinopathy affects the tendon itself—particularly where it attaches to the bone.

Who gets hamstring tendinopathy?

Anyone can get it, but it’s more common in:

• Runners and cyclists
• Athletes who do a lot of sprinting or lunging
• People who sit for long periods, like office workers or drivers

Symptoms and Causes

What causes hamstring tendinopathy?

The most common causes include:

• Repetitive motion (like running, rowing, or cycling)
• A previous hamstring injury that didn’t heal well
• Poor posture or sitting for long periods
• Weak glute muscles or tight hip flexors

What are the symptoms of hamstring tendinopathy?

• Deep buttock pain
• Pain when sitting, especially on hard surfaces
• Discomfort during or after physical activity
• Pain that gets worse with stretching or uphill running

Diagnosis and Tests

How is hamstring tendinopathy diagnosed?

A physio or sports medicine doctor can usually diagnose this through:

• A detailed history and physical exam
• Specific stretch and loading tests (like the bent-knee stretch test)
• In some cases, imaging (like an MRI) to rule out other issues

Management and Treatment

How is hamstring tendinopathy treated?

Treatment usually starts with conservative options, like:

• Rest and avoiding painful activities
• Ice or heat for symptom relief
• Physical therapy, including:
  • Isometric exercises (gentle, static holds)
  • Isotonic exercises (controlled movements)
  • Gradual return to higher-load, sport-specific exercises

Will I need surgery for hamstring tendinopathy?

Most people get better with non-surgical treatment. Surgery is only considered if symptoms are severe and haven’t improved after 6–12 months of rehab.

Prevention

How can I prevent hamstring tendinopathy?

• Warm up properly before exercise
• Strengthen your glutes and hamstrings
• Avoid sudden increases in training volume
• Don’t ignore early signs of pain

Tendinopathy Rehabilitation

Evidence-Based Practice in Tendinopathy

Research shows that graded loading—progressively increasing exercise difficulty—is the best way to help tendons heal.

Managing Difficult Tendinopathies

Chronic cases may need:

• Shockwave therapy
• Platelet-rich plasma (PRP) injections
• A longer, more structured rehab program

Epidemiology / Etiology

Hypothesised Risk Factors:

Intrinsic factors

• Age-related tendon changes
• Muscle imbalances
• Poor flexibility

Extrinsic factors

• Overtraining
• Poor running technique
• Hard surfaces or uneven terrain

Clinical Picture

People with proximal hamstring tendinopathy often describe a deep ache in the buttock, especially when sitting or after exercise. The pain can also radiate down the thigh.

Differential Diagnosis

It’s important to rule out other causes of buttock pain, like:

• Sciatica
• Piriformis syndrome
• Hip joint issues

Diagnostic Procedures

Passive Stretch Tests

Bent-knee stretch test

Stretches the hamstring to see if it reproduces pain.

Modified bent-knee stretch test

Same goal, slightly different position.

The Puranen-Orava test

Involves active stretching of the hamstring.

Palpation of the ischial tuberosity

Direct pressure may trigger pain.

Loading Tests

Checking if resisted hamstring contractions cause discomfort.

Physical Therapy Management

Symptom management – Load modification

Early stages focus on reducing pain by modifying activity and avoiding aggravating movements, inclusion of manual therapy for hamstring pain. 

Rehabilitation

Exercise prescription

Stage 1: Isometric hamstring exercises or loaded movements

Gentle holds to activate the tendon without overloading it.

Appropriate exercises for stage 1

• Isometric long lever hamstring bridge holds
• Static hamstring curls

Stage 2: Isotonic hamstring load with minimal hip flexion

Gradually reintroduce movement.

Appropriate exercises for stage 2

• Single leg hamstring curls
• Single leg hamstring sliders
• Foot elevated long lever hamstring bridge

Stage 3: Isotonic exercises in increased hip flexion (70° – 90°)

Adds more range and complexity.

Appropriate exercises for stage 3

• Stiff legged deadlifts
• Hip hinge exercises
• Long lever hip thrust

Stage 4: Energy storage loading

Simulates sport-specific loads.

Appropriate exercises for stage 4

• Bounding drills
• Sprint mechanics training

Return to Sport After Hamstring Tendinopathy

Returning to sport should be gradual and guided by your physiotherapist. You’ll need full strength, flexibility, and confidence before resuming full activity. Our Penrith physiotherapists put you through a landing, jumping and hopping program to ensure your lower limb tendons are ready for explosive movements.

Other Physical Therapy Management Considerations

• Manual therapy for tight surrounding muscles
• Education on pacing and load management
  
• Including the best exercises for high hamstring tendinopathy

FAQs About Proximal Hamstring Tendinopathy

Q: How long does it take to recover from proximal hamstring tendinopathy?
A: Recovery varies, but most people improve within 3–6 months with proper rehab.

Q: Can I keep exercising with this condition?
A: Yes, but modify activities to avoid aggravating pain. A physio can help guide this.

Q: Will stretching help?
A: Not in the early phase. Too much stretching can make it worse. Focus on strengthening first.

Q: Is massage helpful?
A: It can help ease muscle tightness around the area, but it won’t fix the tendon alone.

FAQs About Sydney Muscle & Joint Clinic

Q: Do you treat hamstring tendinopathy at Sydney Muscle & Joint Clinic?
A: Yes! Our experienced team provides personalised rehab plans for tendon injuries, including proximal hamstring tendinopathy.

Q: Do I need a referral to book an appointment?
A: No referral is needed. You can book directly with one of our physiotherapists or exercise physiologists.

Q: Where are you located?
A: Our physiotherapy clinic is located in Penrith Sydney. Check our website for the nearest clinic to you.

Q: What types of treatment do you offer?
A: For high hamstring tendinopathy, we offer evidence-based physiotherapy, including joint and muscle manual therapy, additional to evidence-based exercise rehab.

If you are looking for a Penrith physiotherapy for hamstring injuries, don’t wait. Early diagnosis and treatment make a huge difference. Contact Sydney Muscle & Joint Clinic today and get started on your recovery journey.