A Pain in the Butt? Understanding Proximal Hamstring Tendinopathy and what you can do about it

Has hiking or sitting been a pain in the butt lately? Does the pain get better with lying down, but seems to increase every time you are active or sitting? Chances are you may have proximal hamstring tendinopathy. 

If you feel lost about what to do about the pain and are frustrated by the limitations it is causing, chances are you will benefit from this blog. I will address several questions that will help you take control, including: 

  1. What is tendinopathy?
  2. What causes tendinopathy to develop?
  3. Proximal hamstring anatomy
  4. How long does it take to recover from tendinopathy?
  5. What are the best treatments for proximal hamstring tendinopathy

What is Tendonopathy

In order to understand tendinopathy it is important to understand tendons and their primary function. Tendons are rope-like structures that connect your muscles to the bone and are primarily composed of collagen. Their primary role is to transmit force from the contracting muscle to move joints (bone). In many ways they act like a spring, stretching and recoiling as force moves through them.

Tendinopathy can occur in any tendon of your body, but is most common in the rotator cuff tendons, the achilles tendon, the patellar tendon, and the hamstrings. It occurs when the normal organization of the tendon becomes ‘abnormal’. Tendinopathy quite literally means ‘Disordered Tendon’. ‘Normal’ tendons are composed primarily of well-organized type I collagen fibers running parallel to each other along with small blood vessels, and nerve fibers. However, this changes when tendinopathy occurs resulting in several changes to the normal structure of a tendon including, but not limited to:

  • Collagen becoming more fragmented
  • A higher proportion of type III collagen fibers are present in the tendon
  • Tendon micro-vascularity increases

Type III collagen fibers are weaker than type I collagen fibers. Likewise, the less organized arrangement and increased vascular growth in the tendon is thought to reduce the strength of the tendon. Because of this, tendons that develop tendinopathy often become less tolerant to load and may become painful.

What Causes Tendinopathy?

Theories of why tendinopathy occurs include dysregulation of tendon function, excessive mechanical loading, inflammation, and apoptosis (cell death) from excessive load. Previously, researchers thought these changes were driven by inflammation and termed this condition ‘tendinitis’. However, tendinopathy has now become the more widely accepted term since more recent research has demonstrated that these changes can occur without an obvious inflammatory response. 

The exact cause of tendinopathy is still somewhat unclear, but research has identified several risk factors involved with its development. Many of the most common risk factors are listed below, many of which can be modified.

Intrinsic factors

Extrensic factors

  • Systemic diseases
  • Metabolic disorders such as diabetes mellitus, obesity and hyperlipidaemia
  • Inflammatory conditions
  • Family history
  • Obesity
  • Age
  • Limited or excessive joint mobility
  • Muscle weaknesses
  • Deficits in neuromuscular control
  • Tendinosis and altered tendon structure
  • Overuse
  • Sudden increase in activity or intensity of activity
  • Initiation of new activities (such as overhead activities for rotator cuff tendinopathy or jumping for patellar tendinopathy, or running for Achilles tendinopathy)
  • Lack of adequate recovery
  • Highly repetitive movement
  • Poor workplace ergonomics
  • Certain Medications including
    • Fluoroquinolones (Antibiotic)
    • Hormone replacement therapy
    • Statins (Cholesterol Medication)

As you can see, many of the risk factors involve repetitive loading, or sudden changes in activity or intensity. However, many other factors are also involved in this process. Understanding these factors can allow you to make behavior changes that allow you to reduce risk for tendinopathy.

Anatomy of the Proximal Hamstrings

ham fig 1 1536x1463 1
From: www.sportsinjurybulletin.com

The Hamstrings are made up of several muscles, 3 of which attach to the pelvis at what is called their ‘Proximal Insertion’.(See image below/Insert image here) The semimembranosus, semitendinosus, and biceps femoris, share a common attachment site and a common tendon. They attach to the part of the pelvis we sit on called the ischial tuberosity, which is the bony prominence you can feel when you press on your lower glutes. Because we frequently sit on these tendons, sitting can be particularly painful when tendinopathy develops. Other activities that ‘compress’ these tendons like lifting your knees high, sprinting, and hiking up inclines can also be aggravating. Modifying these activities while you recover is something that can reduce pain in the short term while you address the underlying issue.

Recovery Time

Experts agree that tendinopathy takes time to recover. (Read more on that HERE.) It is not uncommon for full recovery from tendinopathy to take 6-12 months with good management, and even longer if left untreated. Although many people can have a significant reduction in pain within 12 weeks once they begin rehabilitation. (And more on this HERE).

Starting physical therapy early can get this process started more quickly and allow you to get back to running and training with fewer delays and better tools to manage the process. 

Best Treatments for Hamstring Tendinopathy:

Although it can take time to recover from Tendinopathy, there’s a lot you can do to start making steps toward full function. Below I will discuss the best treatment options for tendinopathy, their benefits, and potential limitations.


Just as repetitive load can be a cause for tendinopathy, appropriate load is also the best solution for tendinopathy. A brief period of rest followed by progressive loading (resistance training) of the tendon is currently considered the first-line treatment. Generally, the load used should generally be kept in a range that keeps pain fairly low when exercising. Working with a physical therapist to establish a plan for how to optimally load the tendon can help you take control of the problem. However, here are a few things ideas to help you get started:

Minimize compression

Compression of the proximal hamstring tendons occurs during sitting, but also when your hip flexes. Temporarily reducing the amount of time you spend sitting can help with this. Exercises should be performed with minimal tendon compression initially. The proximal hamstring tendon is least compressed when the hip is extended and exercises are usually better tolerated with the hip in this position. 

Examples include:

  • Hamstring curls on your stomach, or standing
  • Bridge with feet further from your body
  • Nordic Hamstring variations (more advanced and difficult)

Isometric Exercises

Begin with isometric exercises and progress to slow, heavy, resistance exercises. Isometric exercises are exercises where the muscle contracts, but the joint does not move.

Examples of isometric hamstring exercises include:

  • Bridge with heels far from body
  • Isometric hamstring curl against a band

Individuals often tolerate isometrics with less pain than with exercises where joints move such as squats or deadlifts and are a good entry point. Beginning with isometric type exercises and progressing to heavy resistance exercises performed at a slow tempo can be an effective way to address tendinopathy with less pain. Eventually the goal is to return to doing all of your normal exercises and activities without pain or difficulty.

Extracorporeal Shock Wave Therapy (ESWT)

ESWT is a treatment where pressure waves are transmitted into your tissue to promote healing. It is non-invasive with relatively few side-effects. Evidence has shown that it can be as effective as exercise programs in certain cases of tendinopathy, and has grown in popularity in recent years. It is often used when other conservative treatments have failed, but can be used in earlier management with some really promising results.

Runners’ Edge Alaska is one of very few providers in the state of Alaska that provides this service to our patients. We have had some really impressive results with ESWT and have it available as an option for patients.


Corticosteroid Injections

Corticosteroids are somewhat frequently used to address tendinopathies. They are less invasive than surgery, and have relatively few risks in comparison. However, there is conflicting evidence of their effectiveness. While they may provide short-term pain relief, they can be associated with impaired healing response of the tendon, and increased risk of tendon tearing. Likewise, not all individuals get pain relief following these injections.


Several surgical options exist, with aims at promoting healing of the degenerative tendon. These are not frequently considered for tendinopathy, but procedures exist which can be utilized in specific cases.

Hamstring Tendinopathy does not have to be a "pain in the butt" forever

Although proximal hamstring tendinopathy can quite literally be a “pain in the butt”, you don’t have to let it stop you from doing what you love. With a few adjustments to your life and an appropriate exercise plan, you can get back to doing what you love without pain. 

Hopefully, you now have some tools to get you started on your way back to doing what you love. If you are feeling stuck and like things just aren’t going your way, it can be super helpful to seek the help of a physical therapist.


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