Proximal hamstring tendinopathy is a fairly common posterior hip injury in both active and sedentary people. Due to the complex articular and musculotendinous anatomy in the area, accurate diagnosis is important to help you manage your symptoms and return to activity safely.
What is Proximal Hamstring Tendinopathy?
Proximal hamstring tendinopathy refers to pain in the tendon at the top of your hamstrings, that connects 3 of the 4 hamstring muscles on the back of your thigh to the sitting bones (ischium). The condition occurs when the tendon is overstressed from either repetitive loading, compression, or a combination of the two. This leads to pain, dysfunction and can cause structural changes in the tendon.
Symptoms of Proximal Hamstring Tendinopathy
Proximal hamstring tendinopathy will typically present with localised pain on the sitting bones near the crease of the buttock, aggravated by prolonged sitting, particularly on hard surfaces, as well as hamstring loading activities such as sprinting, longer strides, or walking up hills and stairs. In climbers there may also be pain with climbing in steep terrain and with heel hooks. There may also be pain when trying to touch your toes with your knees straight.
How is Proximal Hamstring Tendinopathy Diagnosed?
Typically diagnosis is based on pain location, and how your pain changes with activity. Tendinopathies commonly have a warming up effect where in the first few minutes of an activity they can be quite sore, but then it starts to settle, only for the pain to re-emerge several hours later or even the next day. A physio will assess tenderness over the sitting bone where the tendon attaches, and may use some specific movements to reproduce the pain. Proximal hamstring tendinopathy also typically does not have one single mechanism of injury, more commonly emerging over a number of days, weeks or months. This slower emergence of symptoms can help differentiate from other injuries such as a muscle or tendon tear.
Key Risk Factors
- Poor load management – rapidly increasing and decreasing the amount of hamstring dominant activities you are doing is a recipe for setting off your tendon.
- Lots of sitting on hard chairs/surfaces
- Tight hamstrings
- Previous hamstring injury(s)
Effective Treatment and Rehabilitation
Treatment for proximal hamstring tendinopathy focuses on improving tendon function and load tolerance through exercise and activity modifications:
- Load management: It is important to recognise how compression of the tendon over your sitting bones effects your recovery. Your physio can help you identify modifications to offload the tendon in compression in order to help the tendon settle down. The other component of this is how much load the hamstring tendon is under. Pain can really settle down with complete rest but then quickly re-emerge as soon as activity is resumed. Your physio can help guide you through an appropriate level of load to avoid the “boom-bust” cycle of intense activity followed by complete rest. Moderation and consistency is the most effective approach here.
- Progressive loading and Exercise: there is fairly limited research surrounding proximal hamstring tendinopathy but there is good quality evidence describing the benefits of heavy strength programs in other lower body tendons such as the achilles tendon. Exercise programs should be tailored to the individual and in this case would general start in a neutral hip position, before gradually progressing into a forward flexed hip position.
- Stable pain: some discomfort is expected during rehabilitation. It is important that this pain is tolerable and stable, meaning it does not increase above a 3-4/10 and settles within 24 hours of exercise.
- Return to Activity: Re-introduction of sports or high intensity activities such as sprinting occur once strength and function are restored. As stated earlier, rushing back into full training or competition can be a recipe for re-aggravation and should only be done once the tendon is sufficiently conditioned.
- Adjunct Treatments: While treatments like icing, massage, or foam rolling may give you temporary relief, they are not a replacement for a structured, consistent rehab program. Injection therapies and surgeries are generally not recommended unless conservative treatments have failed.
How Long Does Recovery Take?
Proximal hamstring tendinopathy recovery can vary by individual but the general trend is 3-6 months of consistent rehab. In more stubborn cases it may take up to a year. This can feel like a long time, but the key to a successful program is a structured and patient approach.
Takeaways
- Proximal hamstring tendinopathy is a common buttock injury typically caused by excessive load or excessive compression of the tendon.
- Managing pain through appropriate exercise is essential for long term recovery.
- Like most tendinopathies, proximal hamstring tendinopathy recovery is a marathon, not a sprint. Consistent exercise and load management are key to improving tendon function over time.
- Avoid quick fixes. Surgery, injections or other invasive treatments are rarely effective and should be reserved for severe cases.
With a tailored rehabilitation plan and a positive, patient mindset, most people with proximal hamstring tendinopathy can fully recover and return to regular activity. If you’re experiencing symptoms you think might be proximal hamstring tendinopathy and want to learn about rehabilitation options, don’t hesitate to reach out to our clinic. Our team of physiotherapists can help guide you through an evidence-based treatment plan to get you back on track.