You’re 14 miles into a long run on the trails. Everything feels decent. Your legs are moving, breathing is controlled… and then it shows up. A dull, nagging ache deep in your sit bone. Maybe one side, maybe both. It tends to fade when you finish, so you write it off as tightness, skip the cooldown stretch you know you should do, and head home.
A few weeks later, it’s showing up at mile 8. Then mile 5. Then on your morning walk to the car.
This is proximal hamstring tendinopathy, and it’s one of the most under-recognized overuse injuries in distance runners.
What Is Proximal Hamstring Tendinopathy?
Your hamstrings are a group of muscles that run along the back of your thigh. They don’t attach directly to bone. They connect via tendons, and at the top end, that tendon anchors to your ischial tuberosity: the bony prominence you sit on. That’s the “proximal” end, and it’s where the trouble starts.
Tendinopathy is a degenerative process that happens when a tendon is repeatedly loaded beyond its capacity to adapt. It’s not a sudden tear or a dramatic snap. It builds quietly over weeks or months of training. We see it a lot in the clinic in runners who have ramped up mileage, added speed work, or returned to training too quickly after a break. The tendon develops microdamage, its structure becomes disorganized, and the result is a tendon that’s both painful and mechanically weaker than it looks on the outside.
What makes this injury particularly sneaky is that it often feels like something else. Many will think it’s just a tight glute, hip flexor soreness, or even referred pain from the low back. Runners stretch, foam roll, and hope it resolves. Sometimes it does. Often it doesn’t.
How Do You Know It’s the Tendon?
The hallmark symptom of proximal hamstring tendinopathy is deep, localized pain at the sit bone specifically at or just below the point where your buttock meets the back of your thigh. Here’s what typically sets it apart:
It hurts when you’re loading the tendon at length. Think running, especially uphill, at speed, or during long efforts. This places the hamstring tendon in a lengthened and compressed position. That’s the sweet spot for tendon pain. Stretching the hamstring can actually make it worse, which runs counter to most runners’ instincts.
Sitting can be uncomfortable, especially on hard surfaces. The tendon is compressed against the ischial tuberosity when you’re seated. Long drives, office chairs, and bleacher seating often aggravate it.
It fades at rest, at first. Early on, the pain tends to settle down after you stop running, which gives you false confidence. Later stage tendinopathy can linger much longer.
Stretching doesn’t help and can hurt. If you’re diligently pulling your heel to your glute or folding forward to touch your toes and the ache keeps getting worse, your tendon is trying to tell you something.
Why Do Marathoners Get This?
High-mileage running places repetitive stress on the proximal hamstring tendon. Risk increases with:
- Rapid mileage increases: Tendons adapt slower than muscles and cardio fitness.
- Hill running & speed work: Higher demand at longer muscle lengths, which provokes the tendon.
- Sitting between runs: Cycles of compression (sitting) and sudden load (running).
- Prior hamstring strain: Can alter loading patterns and increase tendon stress.
- Returning after a break: Tendons lose strength quickly and may not keep up with mileage.
What Doesn’t Work (and Why Runners Keep Trying It Anyway)
- Stretching: Feels intuitive, but lengthening an irritated tendon can make symptoms worse, especially early on.
- Rest alone: May reduce pain short term, but without load, tendons don’t rebuild. Symptoms often return with training.
- Anti-inflammatories: Can help with pain, but don’t address the underlying issue. Tendinopathy is more degenerative than inflammatory.
What Does Work: Load Management and Targeted Rehab
The most effective way to treat tendinopathy is progressive loading. That means slowly and intentionally adding the right amount of stress so the tendon can rebuild and get stronger.
This usually happens in phases:
- Isometric loading (no movement):
These are exercises where you hold a position without moving, like a bridge hold or holding a hamstring curl halfway.
Why it helps: Reduces pain and keeps strength without irritating the tendon. - Isotonic loading (slow strengthening):
This is controlled strength work through movement, like slow Romanian deadlifts, hip hinges, or assisted Nordic hamstring curls.
Why it helps: Builds real strength in the tendon. - Energy storage (return to running demands):
This includes faster, more dynamic movements like skipping, bounding, or eventually running drills.
Why it helps: Prepares the tendon for the impact and spring of running.
A good physical therapist will also look at how you run. Small things like reaching too far in front of your body (overstriding), leaning too far forward, or your hips dropping side to side can overload the hamstring. Fixing these patterns is key to staying pain-free long term. Ask us about our running gait analysis.
ESWT: When the Tendon Needs More Help
For some runners, especially when pain has been hanging around for a while, exercises alone aren’t enough. That’s where Extracorporeal Shockwave Therapy (ESWT) can help.
ESWT is a treatment done in the clinic where gentle pressure waves are applied to the sore area.Think of it like “waking up” a stubborn tendon that isn’t healing well on its own.
Here’s what it does:
- Kickstarts healing: Encourages the tendon to repair itself.
- Improves blood flow: Helps bring nutrients to an area that doesn’t heal easily.
- Breaks up unhealthy tissue: Supports better, stronger tissue rebuilding.
Research shows ESWT can reduce pain and improve function, especially if you’ve had symptoms for a few months or longer.
It’s important to know:
- It’s non-invasive (no needles or surgery).
- It’s done in the clinic and usually takes just a few minutes.
- It works best alongside strength exercises, not instead of them, and done consecutively.
ESWT isn’t a quick fix, but for stubborn cases, it can help restart the healing process and get you progressing again.
Getting Back to Running (The Right Way)
One of the biggest mistakes runners make is going back to running based on how things feel instead of what the tendon can actually handle. Being able to walk pain-free doesn’t mean you’re ready for a long run or hilly trail.
A smart return-to-run plan looks at:
Pain during and after runs:
A little discomfort can be okay, but sharp pain or next-day flare-ups are a sign to pull back.Strength:
Can your hamstring handle load? For example, are you able to do controlled single-leg exercises without pain or fatigue?Running form:
Things like overstriding (landing with your foot too far in front) or hips dropping side to side can overload the tendon.Gradual mileage increases:
Instead of jumping back to 5–10 miles, you might start with short run/walk intervals (like 2 minutes running, 1 minute walking) and build from there.
A sports physical therapist can help you develop a personalized plan to return to running, and keep you running for the long haul.
If This Sounds Like You…
Proximal hamstring tendinopathy is very treatable, especially when you address it early. The longer it lingers without a plan, the longer it usually takes to fix.
At Runners’ Edge Alaska, our sports physical therapists specialize in working with runners and active Alaskans. We understand your goals and focus on keeping you moving, not just getting you out of pain.
If you’re feeling that deep ache near your sit bone on runs, don’t wait for it to get worse. Let’s figure out what’s going on and how to get you back to full training.
