Hamstring Tendinopathy

Proximal hamstring tendinopathy, often called high hamstring tendinopathy, is a stubborn pain at the very top of the hamstring, where the tendon attaches to the sit bone. It’s an uncomfortable and often misunderstood problem: sitting on a hard chair, driving, running uphill and sprinting can all be sore, and it’s often mistaken for sciatica, a back problem or a hamstring strain that won’t heal.

Understanding proximal hamstring tendinopathy

The hamstrings attach to the sit bone through a thick tendon. In tendinopathy, the tendon becomes overloaded and its structure changes, so it’s painful and less able to handle load. It’s affected by both tension, as the hamstrings work hard during running and sprinting, and compression, as the tendon is squashed against the sit bone in positions like sitting and bending forward.

That mix of compression and tension is a key to management, and it’s why aggressive hamstring stretching often makes it worse.

Common contributors include a rapid increase in running, hills or speed work, long periods of sitting, and returning to training after a break.

Symptoms we commonly see

• Deep, aching pain at the base of the buttock, over the sit bone
• Pain sitting, especially on hard surfaces, and when driving
• Pain with running, particularly uphill, sprinting and faster running
• Pain with lunging, bending forward or stretching the hamstrings
• Morning stiffness or pain after sitting for a while
• Pain that sometimes spreads down the back of the thigh

Our evidence-based approach

Clinical guidance for proximal hamstring tendinopathy emphasises accurate assessment, managing the compressive and tensile loads on the tendon, and progressive loading. The research on specific treatments is limited, with a systematic review finding only two randomised trials, so we rely on well-established principles for tendon rehabilitation. Our approach includes:

1. Assessment to confirm proximal hamstring tendinopathy and rule out hamstring strains, lower back referral, deep gluteal pain and hip problems
2. Load management, including reducing compressive positions and adjusting running volume, hills and speed
3. Isometric holds where they reduce pain and make loading easier
4. Progressive strengthening of the hamstrings and glutes, from low-level holds through to heavy, slow strength work and eventually speed and sprint work
5. Hip and trunk strengthening, so the hamstrings aren’t carrying the load alone
6. Sitting and driving advice, such as a cushion or changing position
7. VALD strength testing, so you can see your hamstring strength and track progress
8. A graded return to running and sprinting, in planned steps

See our tendon pain page for how tendon problems are managed generally, and our sciatica page for other causes of pain in the buttock and back of the leg.

What to expect: recovery timeline

• First few weeks: pain often improves as compression is reduced and gentle loading begins
• Around three months: many people have clear improvement with consistent progressive loading
• Long-standing cases: can take longer, which is why starting early and staying consistent matters

When to seek help urgently

Get assessed promptly if your buttock or thigh pain follows a sudden injury with a pop or tearing, you have significant bruising, you can’t walk normally, or you have numbness, weakness or changes in bladder or bowel control. Pain with fever, or constant night pain, also needs review.

References

• Goom TS, Malliaras P, Reiman MP, Purdam CR. Proximal hamstring tendinopathy: clinical aspects of assessment and management. J Orthop Sports Phys Ther. 2016;46(6):483-493.
• Nasser AM, Vicenzino B, Grimaldi A, Anderson J, Semciw AI. Proximal hamstring tendinopathy: a systematic review of interventions. Int J Sports Phys Ther. 2021;16(2):288-305.
• Millar NL, Silbernagel KG, Thorborg K, et al. Tendinopathy. Nat Rev Dis Primers. 2021;7:1.