Proximal Hamstring Tendinopathy
My hamstring hurts and it will not go away….
Proximal hamstring tendinopathy (PHT) is a sneaky overuse injury that hits runners, hikers, and even desk-bound folks hard, causing deep buttock pain that worsens with sitting, stretching, or uphill efforts. As a physical therapist specializing in return-to-sport rehab, I’ve seen it derail weekend warriors and everyday athletes alike. This nagging condition stems from tendon degeneration at the “sit bones,” often from repetitive load or poor recovery. In this article, we’ll break down what tendinopathy means, dive into hamstring anatomy, explore causes and risks, and share prevention tips plus early rehab exercises. Whether you’re chasing elk or just chasing deadlines, understanding PHT can keep you moving pain-free.
What is Tendinopathy?
Tendinopathy is the degradation of a tendon over time, resulting in scarring of the injured fibers. It often involves tendon thickening, partial tears, and inflammation around the tendon, commonly seen in my weekend warrior patients. While tendonitis represents the early, inflammatory stage of a tendon injury involving an immune response, poor blood flow to tendons and subpar rehabilitation often lead to progression into tendinopathy, with fibers scarring and symptoms turning chronic.
Anatomy
Hamstring tendinopathy usually affects the proximal tendons. The hamstrings consist of three muscles—semitendinosus, semimembranosus, and biceps femoris—that originate at the ischial tuberosity, your “sit bones.” When sitting, if you rock your pelvis forward and backward, you’ll feel yourself rolling over these bones. These muscles form the bulk of the muscle mass on the back of your thigh, below the buttocks. Their actions are hip extension and knee flexion. They’re involved in walking or running but emphasized during uphill climbs or stairs.
The long head of the biceps femoris and semitendinosus typically share a common tendon. The semimembranosus has a separate tendon originating just lateral to this, and it’s generally the one diagnosed with PHT.
Complicating this injury is the sacrotuberous ligament, which shares a close relationship with the proximal hamstring tendons at the ischial tuberosity. The hamstrings invest many fibers into this ligament, which inserts into connective tissue around the sacroiliac joint. This connection contributes to tissue degeneration, symptom scope, and exercise choices in treatment.
Causes
PHT is primarily an overuse injury from repetitive loading on the hamstring tendons. Common triggers include sudden increases in training volume or intensity (e.g., uphill mountain biking or trail running, hiking steep grades, or stalking game during elk season), excessive static stretching from yoga or Pilates, and prolonged sitting. Other factors like overtraining, fatigue, and inadequate recovery lead to micro-damage and impaired tendon healing.
PHT isn’t just for weekend warriors. Studies show up to 30% of desk-bound adults report hamstring-origin pain after eight or more hours daily, due to compressive strain on the tendon. Add a long commute—vibration and jolts mimicking repetitive loading—and it worsens quickly.
Risk Factors and Prevention
Examining PHT risk factors reveals key prevention strategies. A prior hamstring injury is the top risk. Additionally, weak glutes or hamstrings, high BMI, or stiff muscles increase vulnerability. Strength training stands out as the best preventive approach. Squats, lunges, and deadlifts (professional instruction advised) are essential exercises for prevention.
Lifestyle tweaks help too. If you sit at a desk for eight or more hours daily, take frequent breaks for short walks or 10 quick squats. If you wind down evenings in front of the TV or screens, spend that time on the floor with hip and leg stretches while streaming your favorite show.
Early Stage Therapeutic Exercises for Proximal Hamstring Tendinopathy
In the early rehab phase for PHT (first 4-6 weeks), focus on isometrics to reduce pain and build tolerance without aggravation. These static holds gently load the tendon, avoiding deep hip flexion or eccentrics. Limit bridges to 30-45 degrees initially; stop if pain increases. Do 3-5 sets of 20-45 second holds, 2-3 times daily, but consult your physio for personalization. Here are three starter exercises.
First: Isometric Double-Leg Bridge. Lie on your back, knees bent at 90 degrees, feet flat hip-width apart. Push through heels to lift hips a few inches—keep shallow to reduce tendon compression. Hold, squeezing glutes and hamstrings without arching your back. This activates the posterior chain safely, ideal for desk workers or runners targeting the proximal area.
Next: Prone Hamstring Isometric Curl. Lie face down, prop on elbows if comfortable, and bend one knee to 30-45 degrees (less if tender). Cross the unaffected leg over the affected ankle for resistance. Press the bent heel upward against the downward pressure, holding without movement. Switch sides after sets. This isolates hamstrings, aids healing via tension, and eases buttock pain.
Finally: Seated Isometric Hamstring Press. Sit with feet flat, knees at 90 degrees. Place a small ball or rolled towel behind one knee and press back gently, engaging the hamstring without shifting. Hold, release, repeat. This accessible move counters sitting strain while preventing early atrophy.
Early rehab demands patience—monitor pain (it should resolve in 24 hours). With progress (full extension, no limp), advance to isotonics. These exercises have helped many patients avoid chronicity; stay consistent!
Proximal hamstring tendinopathy (PHT) doesn’t have to sideline you, whether you’re a trail runner pushing limits or an office dweller glued to your chair. We’ve covered the basics: it’s tendon degeneration from overuse, hitting the semimembranosus hardest at your sit bones, complicated by that sneaky sacrotuberous ligament tie-in. Triggers like sudden training spikes, yoga over-stretches, or endless sitting build up micro-damage, but risks like prior injuries, weakness, or high BMI are preventable with smart moves.
Strengthen those glutes and hams through squats and deadlifts, tweak your lifestyle with desk breaks and evening floor stretches, and in early rehab, lean on isometrics like bridges and curls to ease pain without flare-ups. Consistency pays off—my patients who prioritize gradual loading and recovery often return stronger, dodging chronic woes. If buttock pain lingers, don’t tough it out; book a physio eval to tailor your plan. Stay proactive, and keep moving pain-free—your tendons will thank you!