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Proximal Hamstring Tendinopathy

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Hamstring tendinopathy is an injury to the tendon involving increased load related to tensile and compressive forces. It is most common but not limited to distance runners, athletes performing sports involving high speed sprinting or change of direction (football or hockey) and sedentary patients. Once irritable the tendons capacity to store load is disrupted and injury occurs.


  • Training errors – increasing volume or intensity of training too quickly, like high speed sprints or  hill running

  • Excessive hamstring stretching like an increase in yoga or pilates

  • Hormonal changes such as perimenopausal women (loss of oestrogen affecting tendon repair)

  • Compression of tendon at the attachment site from prolonged sitting on hard surfaces

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Signs & Symptoms

  • Deep localized pain in the region of the ischial tuberosity (attachment site of the hamstring)

  • Pain that warms up after a few minutes of activity but then worsens when you stop

  • Pain with prolonged sitting especially on hard surfaces

  • Morning pain and stiffness

  • No pain on walking, standing and lying

Differential Diagnosis

  • Sciatic nerve irritation at the piriformis muscle

  • Ischiofemoral impingement

  • Hamstring avulsion

  • Deep gluteal muscle tear

  • Posterio pubic or ishial ramus stress fracture

  • Partial or complete rupture of the proximal hamstring tendon

PROmotion Assessment and Outcomes Measures

  1. Pain provocation tests of the hamstring under increased loading

  2. Pain provocation stretch testing and hamstring flexibility

  3. Muscular strength tests of the hamstrings and surrounding muscles such as the gluteals, trunk stabilizers and the lower limb

  4. Functional tests such as Single leg squat control

  5. Postural assessment looking for increased anterior pelvic tilt

  6. Running assessments to identify risk factors such as over striding, increased anterior pelvic tilt and excessive forward trunk lean

  7. The main outcome measure used is the Visual Analogue Scale (VAS) pain scale to determine irritability

How to Manage

The initial stage of management is to reduce pain and irritability. This means modifying activities to stay within what we call the green zone, with a maximum of 3/10 pain rating on the VAS scale being acceptable. Pain must settle within 24 hours otherwise further reduction of loading needs to occur, as this shows hamstring irritability. The use of a load diary can be really useful to track pain, intensity and the 24 hour response and be a useful guide for progression and increased loading. The use of cushions can be useful in the early stages when sitting on hard surfaces to reduce the compression loading and avoiding static stretching and repetitive trunk flexion is recommended to reduce tensile loading.

Training load modification is necessary, but some patients might be able to continue with some slower steady state running, provided that pain stays within the green zone and there is no increase in the 24 hour load response. It is important to avoid hills and high speed sprints in this initial stage and build up slowly, always allowing a day's rest between running days to help with tendon recovery.

Strength exercises, especially eccentric biased and stretch/shorten cycle exercises are important at facilitating muscle hypertrophy, strength and length-tension changes. An individualized targeted rehab program that looks to strengthen the trunk, pelvis and surrounding muscles of the lower leg as well as improving control and movement patterns should be included. Postural modifications such as reducing anterior pelvic tilt in standing and sitting can reduce load. 

Running techniques such as increasing cadence (steps per minute) can significantly reduce the loading of the hamstring tendon and improve running efficiency, and can be monitored with the use of a metronome app. The recommended cadence being 180 steps per minute.  A running plan should be considered to align with patient goals to help avoid training error and spikes in loading with the recommended 10% increase weekly in loading as a safe guide to recovery.


Goom, T., Malliaras, P., Reiman, M., Ppurdam, C.(2016).Proximal Hamstring Tendiopathy Clinical Aspects of Assessment and Management, Vol 46, 483-493.

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